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Purchased  from  the  fund 
established  in  memory  of 

JOSEPH  AND  CHRISTINA  HUBER 

by 

Francis  Huber,  M.D.,  P.  &  S,  '77 


THE  OPERATIONS  OF  OBSTETRICS 


THE  OPERATIONS  OF 

OBSTETRICS 


EMBRACING  THE  SURGICAL  PROCEDURES  AND  MAN- 
AGEMENT   OF    THE    MORE    SERIOUS    COMPLICATIONS 


BY 

FREDERICK  ELMER  LEAVITT,  M.D. 

I'ORMEELY    ASSISTANT    PROFESSOR    OF    OBSTETRICS    AND    GYNECOLOGY,    UNIVERSITY 

OF    MINNESOTA;     OBSTETRICIAN    TO     THE    CITY    AND     COUNTY    HOSPITAL, 

THE    ST.    PAUL    HOSPITAL,    THE    BETIIESDA    HOSPITAL,    ETC., 

ST.    PAUL,     MINNESOTA 


WITH  248  ILLUSTRATIONS 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1919 


f-^-'i^y(yt/^ 


Copyright,    1919,    By    C.    V.    Mosby    Company 


^ 


P}'ess  of 

C.  V.  Mosby  Company 

St.  Louis 


TO 
MY  BROTHER 

SHELDON  LEAVITT,  M.D. 

WHOSE  EXAMPLE  AS  A  MAN  AND  PHYSICIAN 

HAS  BEEN  MY  LIFELONG  INSPIRATION 

I  LOVINGLY  DEDICATE  THIS  BOOK 


PREFACE 

Herewith  is  presented  the  subject  of  obstetrics  from  the  opera- 
tor's point  of  view,  only  enough  pathology  and  physiology  being 
introduced  to  give  reason  for  and  insight  into  the  various  pro- 
cedures described.  Treatment  of  the  subject  from  this  angle  finds 
justification  in  the  hope  and  belief  that  the  general  practitioner, 
as  well  as  the  specialist  in  obstetrics,  will  find  such  a  book  helpful. 

While  much  of  the  material  has  been  gathered  from  personal 
experience,  the  work  represents,  for  the  most  part,  the  cumulated 
knowledge  of  many  teachers  and  writers. 

The  engravings,  without  exception,  are  from  specially  prepared 
drawings  made  by  the  author,  or  by  his  artist,  Mr.  George  M. 
Ericson. 

F.  E.  Leavitt. 

St.  Paul,  Minnesota. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/operationsofobstOOIeav 


CONTENTS 


PART  I 

PAGE 
CHAPTER  I 
General  Preparations 21 

Disinfection,  21 ;  Equipment  and  Posture,  25 ;  Instruments,  30 ; 
Anesthesia.  34;  Assistance,  36. 

CHAPTER  II 
Indications  and  Conditions 37 

Dangers  to  the  Motlier,  37;  Dangers  to  the  Child,  45. 

CHAPTER  III 

The  Artificial  Interruption  op  Pregnancy 49 

Conditions  Due  to  Pregnancy,  49;  Conditions  Due  to  Concurrent  Af- 
fections, 60;  Methods  of  Inducing  Abortion,  67;  Methods  of  In- 
ducing Premature  Birth,  72 ;  Prognosis,  76. 

CHAPTER  IV 

The  Artificial  Dilatation  of  the  Cervix 77 

Colpeurysis,  91. 

CHAPTER  V 

Operations  Designed  to  Increase  the  Pelvic  Diameters 93 

Indications  and  Preparations,  94;  Symphyseotomy,  96;  Pubiotomy, 
98;  The  Prognosis,  104. 

CHAPTER  VI 

The  Correction  and  Treatment  of  Faulty  Attitudes  and  Prolapsed 

Parts • 108 

CHAPTER  VII 
Version 117 

The  Dii3ficulties  Encountered  in  Performing  Version,  134;  Prognosis, 
137;  Dangers  to  the  Mother,  137. 

9 


10  CONTENTS 

CHAPTEE  VIII  PAGE 

Beeech-Birth 141 

Teclmic  of  Extraction,  142;  The  Difficulties  Encountered  in  Birth 
by  the  Breech,  161 ;  The  Injuries  Accompanying  Extraction,  166 ; 
Prognosis,  169. 

CHAPTEE  IX 
Forceps  Operations 171 

Indications  and  Conditions,  171;  Method  of  Procedure,  176;  In 
Abnormal  Positions  of  the  Head,  190;  High  Forceps  Delivery,  194; 
Special  Difficulties  Arising  in  the  Use  of  Forceps,  199 ;  Prognosis 
in   Forceps   Operations,   200;    Expression   of   Fetus,   204. 

CHAPTEE  X 

Perforation  and  Cranioclasis 208 

Indications  and  Conditions,  208;  Method  of  Procedure,  211;  Diffi- 
culties Attending  Perforation  and  Cranioclasis,  225;  Prognosis,  226. 

CHAPTEE  XI 
Embryotomy 228 

Decapitation,  228;  Spondylotomy,  238;  Exenteration,  238;  Atypical 
Conditions  and  Procedures,  238 ;  Prognosis,  240. 

CHAPTEE  XII 

Cesarean  Section 242 

Indications,  243;  Conditions,  246;  Preparation,  247;  The  Conserva- 
tive Operations,  250 ;  The  Conservative  Operations  Compared,  268 ; 
After-Care,  268;  The  Eadical  Operation,  269;  Special  Difficulties 
Encountered  in  the  Performance  of  Cesarean  Section,  272;  Prog- 
nosis and  Statistics  in  Cesarean  Section,  274;  Section  Performed 
on  the  Dead  or  Djang,  276. 

CHAPTEE  XIII 

Vaginal  Cesarean  Section .     .     278 

Indications,  278;  Applicability,  278;  Preparations,  279;  Technic, 
280;  Prognosis,  285. 


PART  11. 

CHAPTEE  XIV 

The  Third  Stage  op  Labor 287 

Manual  Detachment  of  the  Placenta,   294;    Prognosis,   297;    Treat- 
ment of  Inversion,  298. 

CHAPTEE  XV 
Postpartum  Hemorrhage 300 


CONTENTS  11 

CHAPTER  XVI  PAGE 

EUPTURE    OF    THE    UtERUS 308 

Etiology,  308;  Diagnosis,  312;  Prognosis,  312;  Treatment,  313. 

CHAPTER  XVII 
Lacerations  of  the  Cervix 316 

Pi-ognosis,  318. 

CHAPTER  XVIII 

Lacerations  of  the  Vagina 319 

Etiology,    319;    Symptoms,    320;    Diagnosis,    321;    Treatment,    321; 
Prognosis,  322. 

CHAPTER  XIX 

Pressure  Injuries  of  the  Cervix  and  Vagina 323 

Diagnosis,  323;  Treatment,  324;  Prognosis,  324. 

CHAPTER  XX 

Injuries  of  the  Vulva  and  Perineum 325 

Etiology,  325;  Course  and  Symptoms,  325;  Diagnosis,  327;  Prophy- 
lactic Treatment,  327;  Reparation,  332;  Prognosis,  339. 

CHAPTER  XXI 

The  Hemorrhages  of  Childbirth 340 

Placenta  Previa,  340;  Treatment,  343. 

CHAPTER  XXII 

Multiple   Birth 353 

Twdns,   353 ;    Rare   Complications,    355 ;    Further   Observations   Con- 
cerning Twins,  357. 

CHAPTER  XXIII 

The   Transverse  Position 358 

Treatment,  358. 

CHAPTER  XXIV 

Deflections  of  the  Head 365 

The  Occipitoposterior  Position,  365 ;  Presentations  by  the  Face,  366 ; 
Presentation  by  the  Brow,  367. 

CHAPTER  XXV 

Prolapse  of  the  Umbilical  Cord 368 

Treatment,  373. 


12  CONTENTS  : 

CHAPTER    XXVI 

PAGE 

The   Contracted    Pelvis         376 

Classification,    376;    Further    Observations    on    Contractions    of    the 
Pelvis,  396. 

CHAPTER  XXVIT 
Eclampsia 398 

Treatment,  398 ;  Mortality,  401. 

CHAPTER  XXVIII 

Birth  Complicated  by  Tumoes 402 

Ovarian    Tumors,   402 ;    Uterine    Myomata,   404 ;    Carcinoma   of   the 

Uterus,  407;  Tumors  of  the  Vagina  and  Vulva,  408. 

CHAPTER  XXIX 

Malformations   and  Anomalies 410 

Malformations   and   Anomalies    of    the    Maternal    Soft   Parts,   410; 
Malformations  and  Anomalies  of  the  Child,  410. 

CHAPTER  XXX 

Spontaneous   Abortion 416 

Diagnosis,  416;  The  Active  Treatment  in  Abortion,  419. 

CHAPTER  XXXI 
Asphyxia  of  the  Newborn     . 426 

CHAPTER  XXXII 

Extrauterine  Pregnancy 434 

Etiology,  434 ;  Clinical  Aspects,  435 ;  Diagnosis,  438 ;  Treatment,  439. 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Patient  prei^arecl  for   delivery 24 

2.  A  delivery  bed  of  satisfactory  pattern 26 

3.  A  twisted  sheet  used  as  a  leg-holder 27 

4.  Eobb    leg-holder 28 

5.  Trendelenburg  jjosition  secured  by  means  of  a  kitchen  chair     ...  29 

6.  Knee-chest  position 29 

7.  Walcher   hanging    position 30 

8.  Murphy   proctoclysis   apparatus .  50 

9.  Hydatidiform  mole  tilling   the   uterine   cavity 52 

10.  Hydatidiform  mole 53 

11.  Eetroverted   gravid   uterus 56 

12.  Manual  reduction  of  the  retrodisplaced  gravid  uterus 57 

13.  Laminaria  tents     .....     = 68 

14.  Four  sizes  of  the  Hegar  metal  dilators .  69 

15.  Dilating  the  cervical  canal  with  the  Hegar  metal  dilator     ....  70 

16.  Puncturing    catheter 70 

17.  Introducing   the   bougie 72 

18.  Knapp's   elastic   metal  bougie 73 

19.  Kraus's   method   of   inducing  labor 75 

20.  Braun's    rubber    balloon 78 

21.  Two   sizes   of  Voorhees'   hydrostatic   bags 78 

22.  Three  sizes  of  the  Barnes  fiddle-shape  hydrostatic  elastic   dilators     .  79 

23.  Hydrostatic  dilator  in  its  collapsed   state 79 

24.  Introducing   the   hydrostatic  clilator 80 

25.  The  dilator  in  place,  now  being  injected 81 

26.  The   dilator   in   position   and    distended   with   water,    ready   to    begin 

dilatation  by  means  of  traction 82 

27.  Hydrostatic    dilation    of    the    cervix 83 

28.  Ohampetier  de  Eibes  metreurynter  in  position 84 

29.  Bossi  dilator  in  operation 85 

30.  Bossi   metal   dilator 86 

31.  Leavitt  metal  dilator 86 

32.  Dilatation  of  the  cervix  with  the  Leavitt  dilator 88 

33.  Pubiotomy,    open   method 98 

34.  Pubiotomy,   open  method;    shown   in   sagittal   section 99 

35.  Bumni's  pubiotomy  needle •  100 

36.  Pubiotomy,    subcutaneous   method 100 

37.  Pubiotomy,   subcutaneous  method;    shown  in   sagittal   section     .     .     .  101 

38.  Subcutaneous  pubiotomy 102 

13 


14  ILLUSTRATIONS 

^^^-  PAGE 

39.  Subcutaneous  pubiotomy 203 

40.  Dodeilein  saw  carrier   and   saw 103 

41.  The  pubiotom,lzed  pelvis 105 

42.  Vertex  j)resentation  in  the  oblique   diameter 109 

43.  Thorn's  manipulation HO 

44.  Prolapse  of  a  hand  and  foot  in  transverse  position 112 

45.  Prolapse  of  an  arm,  left  occipitoposterior  position 113 

46.  External    version Hg 

47.  Gloved  hand  shaped  for  introduction  into  the  birth  canal     ....  123 

48.  Version  in  the  second  position  of  the  vertex.     First  step     ....  123 

49.  Same  as  Pig.  48.      Second   step 124 

50.  Same   as  Fig.   48    (viewed  from  the   inside)  „ 125 

51.  Same  as  Fig.   48    (viewed  from   the  inside) 126 

52.  Version  in  the  first  dorsoanterior  transverse  position,  the  arm  pro- 

lapsed   127 

53.  Version. in  the  second  dorsoposterior  transverse  position 128 

54.  Same  as  Fig.  48.     Third  step 129 

55.  Inner   view   of  Fig.    54 130 

56.  Version  in  the  second  transverse  position.     F'ourth  step     ....  131 

57.  Version  through  combined  internal  and  external  manipulation     .     .     .  132 

58.  Combined  version  in  the  second  position  of  the  vertex,  placenta  previa 

marginalis 133 

59.  Version  in  the  first  position  of  the  vertex,  shoAving  the  use  of  the 

sling 136 

60.  A   complicating  situation  in   a  transverse  position   after  a   fruitless 

attempt   to   turn 137 

61.  Extraction  by  traction  on  the  foot 142 

62.  Extraction.     Second  step 143 

63.  Extraction.     Third    steji 144 

64.  Extraction.     Fourth  step 145 

65.  Extraction.     Fifth   step 146 

66.  Extraction.     Sixth   step 147 

67.  Extraction.     Seventh    step 148 

68.  Extraction.     Freeing  the  second  arm,  as  seen  from  inside     ....  149 

69.  Extraction.    Freeing  the  posterior  arm,  viewed  from  within  the  pelvis  150 

70.  Extraction.     Eighth  step 151 

71.  Veit-Smellie  method  of  delivering  the  after-coming  head  as  seen  from 

within  the  birth  canal 152 

72.  Delivering  the  after-coming  head  when  it  lies  above  the  pelvic  inlet  153 

73.  Extraction,  both  feet  presenting 154 

74.  Bringing  down  a  foot  in  the  breech  position 155 

75.  Extraction  completed  with  the  finger  iu  the  groin  after  the  breech 

has  been  brought   down   by  some   other   means 156 

76.  Bunge's  sling  carrier     , 157 

77.  Passing  the  Bunge  sling  carrier  about  the  thigh       .......  157 

78.  The    sling    carrier    in    position .  158 


ILLUSTRATIONS  15 

ITIG.  PAGK 

79.  The  sling  carrier  removed,  and  the  sling  in  place  ready  for  tiaction  159 

80.  Smellie's  blunt  hook 160 

81.  Kustner's   breech   hook 160 

82.  Extraction  with  the  Kustner  hook 160 

83.  Posterior  displacement  of  the  arm,  complicating  the  delivery  of  the 

after-coming  head .  162 

84.  Veit-Smellie   method   of   delivering   the   head   supplemented   l)y   ex- 

ternal pressure  on  the  head 163 

85.  Delivery  of  the  after-coming  head  when  the  chin  lies  against  the 

symphysis  pubis      . 165 

86.  Spoon-shaped  depression  in  the  parietal  bone 169 

87.  Chamberlen's  forceps 172 

88.  Levret's  long  forceps,  and  Smellie's  short  forceps 173 

89.  Brown-Simpson   forceps 173 

90.  Tucker-McLane  forceps  with  McClintock  axis-traction  bar  applied     .  174 

91.  Application  of  the  left  blade  of  the  forceps 176 

92.  Another  view  of  the  same  maneuver  as  illustrated  in  Fig.  91     .     .     .  177 

93.  Application  of  the  right  blade  of  the  forceps 178 

94.  Both  blades  have  been  introduced,  and  lie  unlocked,  resting  on  the 

perineum 179 

95.  Locking   the   blades 180 

96.  Forceps  in  position  and  locked 181 

97.  Traction       . 182 

98.  Listening  to  the  fetal  heart  without  interruj)ting  asepsis     .     .     .     .  183 

99.  Supporting    the    perineum 184 

100.  Depressing  the  head  in  freeing  the  anterior  shoulder 185 

101.  Elevating  the  head  in  freeing  the  posterior  shoulder 186 

102.  Applying  the  left  blade  in  the  oblique  diameter  of  the  pelvis     .     .     .  187 

103.  Forceps  applied  in  the  oblique  diameter  of  the  pelvis 188 

104.  A   bad  application   of   the   forceps 189 

105.  Forceps  delivery  in  the  occipitoposterior  position 190 

106.  Forceps   delivery   in   the   mentoanterior   position     . 191 

107.  Forceps  delivery  in  presentation  by  the  brow 192 

108.  High    forceps    delivery 195 

109.  Tarnier  axis-traction  forceps 197 

110.  Delivery  with  the   axis-traction   forceps 198 

111.  Hematoma  of  the  cheek,  due  to  injury  from  forceps 203 

112.  Kristeller's    expression 206 

113.  The  Naegele  perforator 210 

114.  Smellie  perforator 210 

115.  Kiwisch-Martin  trephine  with  obturator 212 

116.  Braun-Gessner   cranioclast 212 

117.  Tribladed  cranioclast 218 

118.  Mesnard-Stein  bone  forceps.     Curved.     Alligator  teeth 213 

119.  Mesnard-Stein  bone  forceps.     Straight.     Peg  teeth 214 

120.  Irrigating  cannula 214 


16  ILLUSTRATIONS 

^'I<^-  PAGE 

121.  Perforating  the  advanciiio-  head  with  the  Naegele  perforator     .     .     .  215 

122.  Trephining  the  head   with  tlie   Kiwisch-Martin   trepliine     ....  216 

123.  Forcing  water  into  the  trepMned.  head  through  a  cannula  after  the 

brain  substance  has  first  been  broken  up  by  it 217 

124.  Perforation  of  the  after-coming  head  with  the  Naegele  perforator     .  218 

125.  Dissection  of  the  neck,  sliowing  the  course  of  the  perforator     .     .  219 

126.  Cranioclasis 220 

127.  Cranioclasis.     Seen  from  the  inside 221 

128.  Ci-anioclasis.    The  compression  screw  to  its  maximum  has  been  tight- 

ened, firmly  fastening  the  cranioelast  to  the  child's  head     .     .  222 

129.  Extraction  with  the  cranioelast 223 

130.  Shoulder  presentation,  with  prolapse  of  the  arm 229 

131.  Brauu's  decapitation  hook 231 

132.  Siebold's  decapitation  scissors 231 

133.  Decapitation  with  the  Braun  hook.    Introducing  the  hook     ....  233 

1 34.  Decapitation  with  the  Braun  hook.     The  instrument  has  been  placed 

about  the  child's  neck 234 

135.  Following  decax^itation,  the  headless  trunk  of  the  cliild  is  delivered 

by  making  traction  on  the  protruding  arm 235 

136.  Manual  extraction  of  the  decai^itated  head 236 

137.  Evisceration 237 

138.  Surgeon  prepared  for  oi^eration 249 

139.  Cesarean    section 251 

140.  Topograijhy  of  the  uterus  at  the  end  of  pregnancy 253 

141.  Cesarean    section.      Interrux^ted    and    continuous    suturing    of    the 

irterine    incision 254 

142.  Closing   the    abdominal    incision 255 

143.  Overlaying  the  free  aponeurosis  of  one  side  with  that  of  the  other     .  256 

144.  Approximating  the  peritoneal   surface  of   one  flap   to   the   aponeu- 

rosis of  the  other,  and  suturing  its  free  edge  thereto     ....  257 

145.  Applying    the    Michel    metal    clips 258 

146.  Transverse  abdominal  incision.    Incising  the  fascial  layer     ....  259 

147.  Transverse  abdominal  incision.    Blunt  separation  of  the  fascia  from 

the  underlying  muscle;   its  median   attachment  is  severed  with 

scissors 259 

148.  Suprasymphyseal   cesarean    section 261 

149.  Suprasymphyseal   cesarean   section 261 

150.  Transperitoneal  cervical  cesarean  section 262 

151.  Opening   the  uterus 263 

152.  Bringing  the  child's  face  into  the  uterine  opening 264 

153.  The  face  of  the  child  has  been  brought  into  the  opening,  and  is  held 

there  until  the  forceps  is  applied 265 

154.  Suturing   the   uterine   wound 266 

155.  The  detached  bladder  is  being  replaced  over  the  wound  in  the  uterus  267 

156.  Supravaginal  amputation   of  the  uterus,  with   conservation  of   one 

ovary 270 


ILLUSTRATIONS  17 

FIG.  PAGE 

157.  Closing  over  the  cervical  stump 271 

158.  Vaginal    cesarean    section 280 

159.  Separating  and  pushing  back  the  bladder  from  the  cervix     .     .     .  281 

160.  Closing   the   A'aginal   mucous    membrane 283 

161.  Closing  the  incision  in  the   cervix 284 

162.  Placental  separation  and  expulsion  as  descril^ed  bj'  Schultze     .     .     .  288 

163.  Placental  separation  and  exxaulsion  as  described  by  Duncan     .     .     .  289 

164.  Expressing  the  placenta 290 

165.  Placenta  with  three  secondary  portions 291 

166.  Manual  separation  and  removal  of  the  placenta 296 

167.  Complete  inversion  of  tlie  puerperal  uterus,  with  the  placenta  still 

attached 298 

168.  Bimanual  compression   of  the  uterus  in  postpartum  hemorrhage     .  301 

169.  Constriction  of  the  waist  with  the  Momburg  tube  to   control  hem- 

orrhage         302 

170.  Packing  the  uterus  with   gauze 303 

171.  Introducing    normal    salt    solution    into    the    basilic    vein    by    the 

gravity   method        304 

172.  Basilic  vein  prepared  for  infusion,  and  the  cannula 305 

173.  Introducing  normal  salt  solution  into  the  basilic  vein  by  the  air- 

pressure  method 306 

174.  Eupture  of  the  gravid  uterus 309 

175.  Complete  rupture  of  the  uterus 310 

176.  A  tear  through  the  cervicovaginal  commissure,  following  version  and 

extraction 311 

177.  Suturing  the  lacerated  cervix 317 

178.  The  claw  forceps 320 

179.  Illustrates  how  in   prolonged   arrest   of   the  head  pressure   against 

the  bony  prominences  of  the  pelvis  may  be  the  cause  of  local 

necrosis,    etc 323 

180.  The  levator  ani  muscle 326 

181.  Supporting  the  perineum  in  the  lateral  position 328 

182.  Supporting  the  perineum  in  the  dorsal    position 329 

183.  Episiotomy.     Severing  the  introitus 330 

184.  Topography  of  the  pelvic  floor  and  introitus 331 

185.  Exposing  the  lacerated  area  with  Dr.  Gilpi's  forceps 334 

186.  Repairing  the  lacerated  perineum  (incomplete  tear) 335 

187.  Repairing  the  lacerated  perineum   (complete  tear) 337 

188.  Episiotomy.      The   first   suture   in   place 338 

189.  Complete   or   central   placenta   previa 341 

190.  Placenta  previa;  placenta,  fetus,  and  amnion  born  intact  at  seven 

months ^^-^ 

191.  The  fetus,  placenta,  and  amnion  shown  in  Fig.  190  separated     .     .  344 

192.  Lateral,   partial,   and   complete   placenta   previa 345 

193.  Bipolar  version  in  placenta  previa 346 

194.  Premature  separation  of  the  normally  placed  placenta 349 


is  ILLUSTRATIONS 

FIG.  PAGE 

195.  Interlocking-   heads   in   the   l>irth   of    twins 356 

196.  Spontaneous    evolution 359 

197.  Spontaneous    evolution 360 

198.  Partus   conduplicato    corpore 361 

199.  Spontaneous  evolution  in  a  eross-liirth 361 

200.  The  arm  prolapsed 362 

201.  The  occiput  has  rotated  almost  directly  anterior  and  lies  just  above 

the  pubis 362 

202.  The  child  has  undergone  a  movement  of  rotation 363 

203.  Presentation,   or   forelying,   of   the   umbilical   cord,   the  membranes 

unruptured 369 

204.  Prolapse  of  the  cord 370 

205.  Instrumental  reposition  of  the  cord  by  means  of  a  threaded  catheter  371 

206.  Detail  of  threaded  catheter  with  a  loop  of  thread  entwined  about 

the   cord 372 

207.  The   more   common   types   of   pelvic   deformity   compared   with   the 

normal 377 

208.  The   spondylolisthetic   pelvis 378 

209.  Ideal  female  figure  showing  the  rhomboid  of  Miehaelis 379 

210.  Breisky's  pelvimeter 380 

211.  Female  figure  with  pelvis  and  lines  of  measurement  outlined     .     .     .  381 

212.  Taking  the  interspinal  and  intercristal  measurements 382 

213.  Measuring  the  external   conjugate 383 

214.  Measuring  the  intertuberal  diameter  of  the  outlet 384 

215.  Measuring  the  anteroposterior  diameter  of  the  outlet 385 

216.  Faust's  pelvimeter  for  the  direct  measurement  of  the  internal  con- 

jugate  diameter 386 

217.  Manual  measurement  of  the  internal   conjugate 387 

218.  Chondrodystrophie   dwarf 388 

219.  Simple   rachitic    pelvis 389 

220.  Colored  woman  with  fiat  rachitic  pelvis 389 

221.  Head-molding 391 

222.  The   anterior   parietal   bone,   held   by   the   symphysis   pubis   as   the 

posterior  bone  slides  over  the  promontory  of  the  sacrum     .     .     .  392 

223.  Molding  of  the   shoulders 393 

224.  Ovarian   cyst   obstructing   birth 403 

225.  A  large  myoma  complicating  pregnancy 404 

226.  A  submucous  myoma  of  the  lower  segment  of  the  uterus  lying  in 

advance  of,  and  acting  as  an  obstruction  to,  the  head     ....  405 

227.  An  obstructing  myoma 406 

228.  Edema  of  the  vulva 408 

229.  Auencephalus 411 

230.  Hydrocephalus 412 

231.  Draining  off  the  water  from  a  hydrocephalic  head  by  means  of  a 

catheter  introduced  through  a  puncture  in  the  spine     ....  413 

232.  Cross  section  of  Fig.   232 414 


ILLUSTRATIONS  19 

FIG.  PAGE 

233.  Pregnancy   at   three   months 419 

234.  Three  months'  ovum  with  sac  and  placenta  uitact 420 

235.  Reaming  out  the  ovum  with  the  tinger 422 

236.  Winter's  abortion   forceps 424 

237.  Extracting  the   ovum  witli  the   abortion   forceps 425 

238.  Mucus   aspirator 427 

239.  Making  traction  on  the  baliy's  tongue  as  the  cliihl  lies  in  a  tub  of 

warm  water 428 

240.  Aspirating  the  larynx   soon   after  birth 429 

241.  Schultze   method    of    resuscitation 430 

242.  Introducing   the   tracheal   catheter 431 

243.  Lungmotor 432 

244.  Lungmotor  in  opieration     . 433 

245.  Extrauterine  pregnancy — tubal  abortion 435 

246.  Extrauterine  pregnancy — intraligamentous 436 

247.  Decidual    cast , 439 

248.  Extrauterine   pregnancy;    the   tube    on   the   ruptured    side    clamped 

ready   for    ligation    and   resection 440 


PART  I 

THE  SURGICAL  PROCEDURES 


CHAPTER  I 
GENERAL  PREPARATIONS 

DISINFECTION 

The  same  principles  of  asepsis  apply  to  obstetric  surgery  that 
apply  to  other  surgery,  and  should  be  observed  with  the  same 
rigidity.  Normally,  the  parturient  tract  is  self-protective,  the 
ordeal  of  birth  not  disturbing  this  security  except  through  un- 
usual conditions  or  from  outside  contamination.  Beginning  at 
the  introitus  and  extending  up  the  birth  canal,  the  seriousness 
of  infection  progressively  increases  as  it  rises.  Pyogenic  micro- 
organisms not  only  thrive  better  above  than  below,  but  the  con- 
sequences of  their  activity  are  relatively  more  dangerous.  In 
this  respect  obstetric  surgery  differs  from  general  surgery.  The 
field  of  operation  frequently  lies  within  or  through  a  tract  that 
is  not  easily  asepticized. 

Microorganisms  reach  this  inviting  field  in  tAVO  ways:  (1)  they 
may  be  carried  there  at  time  of  labor  through  examination  and 
manipulation,  and  (2)  they  may  have  found  lodgment  in  the 
vagina  or  vulva  before  labor,  only  to  become  virulent  from  puer- 
peral incubation.  And  no  matter  hoAV  exacting  one  may  be,  it 
is  never  possible  to  free  the  maternal  parts  absolutely  of  germs. 
It  has  been  shown  by  Bumm  that  in  three-fourths  of  his  cases 
streptococci  were  found  on  the  vulva  and  in  the  vagina.  Gen- 
erally speaking,  these  germs  are  harmless  so  long  as  they  re- 
main where  they  are  and  the  tissues  remain  intact;  but,  when 
carried  by  the  hand  or  instrument  to  a  higher  and  less  protected 
surface  like  the  placental  site,   their  activities  at  once  become 

21 


22  THE    SURGICAL   PROCEDURES 

exceedingly  troublesome.  To  protect  from  such  dangers,  every 
obstetric  procedure  should  be  preceded  by  careful  disinfection 
both  of  the  operator  and  the  one  operated  on.  First,  let  us  con- 
sider the  former. 

1.  The  Disinfection  of  the  Operator. — The  hands  and  arms 
must  be  free  from  wounds  and  abrasions ;  they  should  never  be 
brought  unprotected  in  contact  with  pustular  or  septic  objects; 
and  they  should  be  thoroughly  prepared  immediately  before 
every  operation  or  vaginal  examination.  The  street  clothes 
should  be  replaced  with  freshly  laundered,  short-sleeved  linen  coat 
and  trousers.  Over  these  and  for  their  protection  is  fastened  a 
long  apron  made  of  rubber  or  other  Avaterproof  material.  Finger 
rings  must  of  course  be  taken  off,  and  the  arms  bared  to  well 
above  the  elbows. 

The  details  of  hand  scrubbing  and  disinfection  are  as  folloAvs: 

(1)  Scrub  the  hands  and  arms  in  running  water  with  soap  and 
brush  for  five  minutes.  The  kind  of  soap  used  is  not  so  important 
as  the  thoroughness  of  the  scrubbing.  Liquid  soap  can  be  man- 
aged a  little  more  aseptically  than  bar  soap,  but  really  is  no  bet- 
ter.    Even  a  pumice  soap  sometimes  may  be  used  to  advantage. 

(2)  Dry  the  hands  with  a  soft  towel;  clean  under  the  nails  and 
at  their  base  with  a  suitable  half-sharp  nail-cleaner;  cut  the 
nails  short,  and  trim  off  all  loose  particles  of  skin.  (3)  Wash 
again  for  five  minutes  in  sterile  hot  water,  using  a  sterile  brush 
as  before.  (4)  Dry  the  hands  on  a  sterile  towel.  (5)  Eub  the 
hands,  especially  the  fingers,  in  80  to  96  per  cent  alcohol  with  a 
sterile  gauze  sponge  for  three  minutes.  (6)  Brush  the  hands 
for  tAvo  minutes  longer  in  a  1  per  cent  lysol  solution.  The  hands 
should  then  be  covered  with  sterile  rubber  gloves. 

2.  The  Preparation  and  Sterilization  of  Rubbet  Gloves. — The 
gloves  should  first  be  thoroughly  washed  with  soap  and  warm 
water,  then  rinsed  in  clean  water  and  boiled  for  ten  minutes. 
Next,  they  are  dried,  both  inside  and  out,  and  powdered  freely 
with  talcum.  It  is  of  further  advantage  to  stuff  into  the  gloves, 
especially  the  fingers,  a  strip  of  gauze,  the  meshes  of  which  are 
filled  with  the  powder,  for  the  surfaces  are  thereby  kept  from 
agglutination  in  the  process  of  sterilization,  and  the  impregnated 
gauze  makes  a  serviceable  powder  puff  for  the  hands  when  draw- 
ing on  the  gloves.     Obviously,  the  gauze  must  be  withdrawn 


GENERAL   PREPARATIONS  23 

from  the  gloves  before  they  can  be  put  on,  and  the  hands  must  be 
dry.  After  the  gloves  have  been  washed,  dried,  and  powdered 
as  directed,  they  are  wrapped  in  pairs  and  steam-sterilized.  Pre- 
pared in  this  way  gloves  are  always  ready  for  use.  Another  and 
more  common  way  is  to  boil  the  gloves  for  ten  minutes  just  be- 
fore operating.  They  are  then  drawn  on  wet,  or,  better  still, 
full  of  water.  Immersed  in  a  lysol  solution,  the  fingers  become 
distended,  and  the  glove  pulls  on  easily.  After  the  water  is 
pressed  out,  folds  in  the  rubber  are  easily  smoothed  out  by  strok- 
ing with  a  brush  or  piece  of  gauze. 

3.  The  Disinfection  of  the  Patient. — The  patient  should  re- 
ceive a  full  bath  shortly  before  the  onset  of  labor,  or  soon  after  it 
has  begun.  The  entire  body  is  soaped,  except  the  genitalia.  If 
the  amniotic  sac  has  ruptured,  a  full  bath  should  not  be  given, 
at  least  not  a  tub  bath.  Particularly  is  the  tub  bath  objected  to 
for  the  multipara,  with  Avhom  there  may  be  considerable  relaxa- 
tion of  the  perineum.  Where  obtainable,  the  shower  bath  is 
preferable.  A  full  bath  would  also  be  contraindicated  in  eclamp- 
sia, placenta  previa,  and  severe  internal  diseases,  such  as  heart 
affections  and  pneumonia.  After  the  bath,  the  bowels  should 
be  emptied,  a  simple  movement  answering  if  the  patient  can 
defecate  shortly  before  labor  begins.  A  clyster  is  more  to  be 
relied  upon,  hoAvever;  otherwise,  one  is  never  sure  that  the  rec- 
tum has  been  thoroughly  emptied;  and,  unless  it  is,  delivery  will 
be  impeded,  and  fecal  matter  will  be  expelled  at  a  time  Avhen 
cleanliness  is  particularly  desirable. 

4.  The  Disinfection  of  the  Genitals. — Disinfection  of  the  gen- 
itals is  carried  out  as  follows:  (1)  Remove  the  pubic  and  vulval 
hair.  Clipping  may  answer,  but  shaving  admits  of  more  thor- 
ough disinfection.  (2)  With  soap  and  warm  water  wash  thor- 
oughly the  external  parts,  including  the  vulva,  the  anus,  the  in- 
ner surfaces  of  the  thighs,  and  the  lower  part  of  the  abdomen. 
A  stiff  brush  should  not  be  employed,  but,  instead,  an  ordinary 
wash-cloth,  or  a  piece  of  gauze.  (3)  Rinse  off  the  parts  with 
sterile  water.  Ordinarily,  this  is  sufficient  disinfection,  but  it 
should  include  the  vagina  if  there  is  much  discharge. 

Very  often  the  operator  himself  completes  these  preparations 
while  the  patient  is  being  anesthetized.  When  fully  under  the 
anesthetic,  the  vulva  is  thoroughly  rubbed  with  gauze  saturated 


24 


THE    SURGICAL   PROCEDURES 


with  alcohol,  the  bladder  is  catheterized  and  the  vagina  irrigated 
vith  a  1  per  cent  lysol  solution.  To  insure  thoroughness  in  the 
vaginal  disinfection,  the  finger  may  a'ccompany  the  douche  point, 
and  gently  wash  the  parts  out  as  the  solution  tiovs  into  the  canal. 
Upon  completing  the  disinfection,  the  loAver  extremities  and 


/ 


i 


1 


Fig.     1. — Prepared     for     delivery.         The    parts     have     been    shaved,    and    painted    with 
iodine.      Chloroform    is    being    given,    a    few    drops    with    each    pain. 

abdomen  are  covered  with  clean  or,  better  still,  sterile  sheets, 
toAvels,  or  specially  designed  draperies  (Fig.  1). 

That  such  precautionary  measures  are  followed  by  better  re- 
sults than  formerly,  when  disinfection  was  practiced  Avith  indif- 
ference or  neglected  altogether,  one  has  only  to  refer  to  statis- 


GENERAL   PREPARATIONS  ,  25 

tics  in  order  to  be  convinced.  Before  the  introduction  of  asepsis 
and  antisepsis,  the  average  mortality  from  puerperal  infection 
in  hospital  practice  Avas  3  per  cent.  Following  the  general  in- 
troduction of  more  precise  methods  of  disinfection,  the  mortal- 
ity has  been  reduced  to  a  fraction  of  1  per  cent.  Formerly,  one 
puerperal  death  occurred  in  every  thirty-three  women  delivered, 
as  compared  with  one  in  a  thousand  now.  The  percentage  of 
morbidity  was  also  high.  Every  tenth  patient  suffered  an  infec- 
tion that  ran  a  course  only  short  of  death.  Proof  that  the  hands 
and  instruments  are  the  conveyors  of  infection  is  strengthened 
by  the  fact  that  about  40  per  cent  of  the  women  dying  during 
the  puerperium  have  undergone  operations,  which  operations  are 
to  be  regarded,  not  always,  but  frequently,  as  having  been  re- 
quired by  a  pathologic  condition  demanding  surgical  interven- 
tion for  her  sake.  The  unfortunate  ending,  however,  is  charged 
to  puerperal  infection. 

EQUIPMENT,  POSTURE,  ETC. 

Obstetrics  as  practiced  in  the  hospital  is  far  different  from 
what  it  is  when  practiced  in  the  private  house.  While  the 
patient's  home  may  be  satisfactory  in  some  instances,  the  hos- 
pital is  so  much  better  and  safer  that  every  woman  should  be 
urged  to  avail  herself  of  its  advantages.  Some  day  it  will  be 
the  exception  rather  than  the  rule  for  babies  to  be  born  at  home. 
But  until  that  time  comes  it  will  be  necessary  to  apply,  as  far  as 
possible,  the  same  aseptic  principles  there  as  in  the  hospital. 
Useless  pieces  of  furniture,  heavy  draperies,  and  all  but  the 
simplest  ornamentation  had  better  be  removed  for  the  occasion. 
There  should  be  some  provision  made  for  artificial  light  that 
can  be  directed  upon  the  introitus;  and  for  this  purpose  a  lamp 
with  a  reflector,  preferably  an  electric  light,  is  best  adapted 
for  the  purpose. 

Delivery  Bed. — The  delivery  bed  should  be  of  plain  metal, 
one-half  to  two-thirds  as  wide  as  the  usual  household  bed.  It 
should  be  of  good  height,  fitted  with  stiff  springs  and  a  firm  mat- 
tress, and  stand  free  on  both  sides.  After  delivery  the  patient 
may  lie  in  a  more  comfortable  bed,  the  one  she  is  accustomed  to, 
if  she  prefers.  The  bed  linen,  as  well  as  the  linen  of  the  patient, 
must  be  scrupulously  clean  and  freshly  laundered.     Over  the 


26 


THE    SURGICAL   PROCEDURES 


mattress  and  beneath  the  sheet  is  spread  a  piece  of  waterproof 
material  a  yard  or  more  long,  and  wide  enough  to  extend  several 
inches  over  the  sides  of  the  bed. 

A  better  but  more  elaborate  way  of  preparing  the  delivery 
bed  is  to  make  what  is  known  as  the  double  bed.  Two  pieces 
of  the  waterproof  material  and  two  sheets  are  used,  instead  of 
the  single  arrangement.  A  rubber  sheet,  next  to  the  mattress 
is  pinned  as  above  described,  OA^er  which  is  placed  a  linen  sheet, 
also  pinned  to  the  mattress.  This  sheet,  in  turn,  is  overlaid  with 
a  second  piece  of  rubber  cloth,  and  covered  with  linen.     At  the 


Fig.  2. — A  delivery  bed  of  satisfactorj-  pattern.  It  is  so  constructed  that  the 
head  can  be  elevated  and  the  feet  braced  ;  and  it  can  be  separated  and  the  patient  easily 
and    readily    placed    in    position    for    operative    procedures. 

conclusion  of  labor  the  upper,  or  draw-sheet,  together  with  its 
accompanying  one  of  rubber,  as  well  as  all  soiled  pads  and 
dressings,  are  removed  from  beneath  the  patient,  leaving  the 
mattress  well  protected  from  any  further  discharge  that  may 
occur. 

For  most  of  the  obstetric  procedures  it  is  necessary  to  have 
the  patient  lie  crosswise  on  the  bed,  except  Avhere  a  regular  de- 
livery bed  is  used.  With  the  hips  well  over  the  edge,  the  thighs 
iiexed,  and  the  knees  separated,  it  is  possible  to  prepare  the  sur- 
faces i^roperly,  and  to  perform  whatever  operations  may  be  in- 
dicated.    The  regular  obstetric  bed  is  so  constructed  that  the 


GENERAL   PREPARATIONS  27 

patient's  hips  can  be  brought  clown  to  the  foot,  and  the  limbs 
held  in  proper  position  by  means  of  stanchions  attached  to  the 
bed  (Fig.  2).  A  chair  for  the  operator  to  sit  on,  a  pillow  under 
the  patient's  head,  a  large  bowl  or  bucket  under  the  edge  of  the 
bed  to  catch  the  discharges,  and  plenty  of  clean  towels,  are  some 
of  the  things  to  have  in  readiness.  And  various  kinds  of  pads 
for  purposes  of  absorption  are  also  in  demand.  There  is  no 
objection  to  the  pneumatic  pad,  except  that  it  is  cumbersome  to 
carry  about.  It  is  more  essentially  a  part  of  hospital  armamen- 
tarium. Any  waterproof  cloth  folded  in  at  the  sides  and  top 
answers  the  purpose.    After  the  scrubbing  and  disinfecting  proc- 


( 


Fig.    3. — A    twisted    sheet    used    as    a    leg-holder. 

ess  is  ended,  nothing  but  sterile  towels  overlying  an  absorptive 
pad  are  to  be  used  near  the  genital  parts.  The  matter  of  light 
is  important,  and  should  be  so  arranged  that  it  shines  over  the 
physician's  shoulder  as  he  sits  facing  the  patient. 

For  all  formidable  procedures  a  regular  operating  table  is  of 
distinct  advantage.  Sometimes,  however,  it  is  necessary  to  make 
use  of  what  comes  to  hand,  impressing  into  service  the  dining  or 
kitchen  table.  The  chief  advantage  of  the  table,  as  compared 
with  the  bed,  is  its  height  and  rigidity.  Placed  upon  it,  the  legs 
of  the  patient  are  supported  by  two  assistants  who  stand  on 
either  side  of  the  table.  In  the  absence  of  such  help  a  sheet 
may  be  twisted  into  a  rope,  and  carried  around  the  patient's' 


28 


THE    SURGICAL   PROCEDURES 


neck  and  under  one  shoulder  to  the  knees,  "where  the  ends  are 
fastened  as  the  woman  lies  "with  the  thighs  well  flexed  on  the 
abdomen  (Fig.  3).  The  Eobb  leg-holder  (Fig.  4)  is  an  improve- 
ment on  the  sheet ;  the  Hirst  device  has  the  further  advantage  of 
holding  the  knees  apart. 

For  some  purposes  the  side  position  is  of  advantage.  It  is 
difficult  with  the  patient  lying  on  her  back  to  reach  with  the  hand 
the  anterior  wall  of  the  uterus,  as  sometimes  is  necessary  in  per- 
forming version  or  in  loosening  an  adherent  placenta.  If  the 
operator  already  has  his  hand  in  the  uterus,  and  wishes  to  change 
from  one  position  to  the  other  in  the  midst  of  a  maneuver,  it  can 
readily  be  done  by  an  assistant  lifting  the  patient's  leg  over  the 
accoucheur's  head  without  the  necessitv    of    withdrawing    his 


Fig.     4. — Robb     leg-holder. 

hand.  The  lateral  position  is  also  employed  to  advantage  dur- 
ing the  perineal  stage  of  labor,  though  it  can  not  be  maintained 
very  long  at  a  time  unless  the  woman  lies  lengthwise,  instead  of 
crosswise,  on  the  bed.  The  position  is  contraindicated  in  jDla- 
centa  previa  because  of  the  increased  danger  from  embolism. 

High  Elevation  of  the  Pelvis. — The  high  elevation  of  the  pelvis 
is  of  particular  value  in  reposition  maneuvers,  such  as  the  resto- 
ration of  a  prolapsed  tumor,  the  release  of  an  incarcerated  retro- 
flexed  uterus,  or  the  replacing  within  the  pelvis  of  a  fallen  loop 
of  the  umbilical  cord.  The  position  is  easily  secured  on  the 
operating  table  by  lowering  the  head  to  the  Trendelenburg  posi- 
tion. In  the  home  it  can  be  secured  by  means  of  a  common 
kitchen  chair  so  placed  on  the  table  or  bed  that  the  knees  of  the 


GENERAL   PREPARATIONS 


29 


patient  fall  over  the  lower  back  round  of  the  chair  (Fig.  5). 
The  chair  first  shonlcl  he  covered  Avith  a  thick  blanket  and  a 
clean  sheet. 


Fig.    5. — Trendelenburg  position   secured  by   means   of  a  kitchen   chair. 


Fig.     6. — Knee-chest    position. 

Knee-chest  Position. — The  knee-chest  position  is  especially  use- 
ful in  the  more  troublesome  forms  of  funic  prolapse.  By  it  the 
fundus  of  the  uterus  sinks  forward  into  the  deepest  part  of  the 
abdomen,  thereby  favoring  the  retention  of  the  reposed  part  in 


so 


TSE    surgical   PROCEDUlREg 


a  safe  position  until  the  advancing  head  obstructs  its  further 
dislocation.  The  posture,  on  the  other  hand,  induces  a  negative 
pressure  in  the  abdomen,  which  greatly  increases  the  difficulties 
of  narcosis.     (Fig.  G.) 

Walcher  Hanging  Position. — The  Watcher  hanging  position, 
also  a  very  awkward  one  for  a  woman  in  labor  to  assume,  has  a 
limited  use.  Bringing  the  buttocks  of  the  patient  to  the  edge 
of  the  table,  and  allowing  the  feet  to  hang,  will,  it  is  calculated, 
increase  the  true  conjugate  three-fourths  of  a  centimeter 
through  rotating  the  sacrum  on  its  iliac  articulation.  The  pos- 
ture finds  its  chief  advantage,  therefore,  in  flat  pelves,  and  may, 
in  certain  cases,  increase  the  diameters  enough  to  allow  the  ad- 
vancing or  after-coming  head  to  engage.     (Fig.  7.) 


Fig.    7. — Walcher    hanging   position. 


INSTRUMENTS 

Obstetric  instruments,  the  same  as  other  surgical  instruments, 
ought  to  be  kept  in  a  suitable  cabinet.  For  convenience  in  car- 
rying instruments,  one  should  have  a  satchel  large  enough  to 
accommodate  all  the  instruments  and  appliances  necessary  for 
performing  any  obstetric  operation  that  may  arise.  Such  satchels 
are  to  be  found  in  many  varieties  at  the  instrument  dealers'  ware- 
rooms.  To  be  practical,  the  satchel  or  bag  must  be  so  planned 
that  one  can  pack  or  unpack  it  quickly.  I  have  found  it  very 
convenient  to  group  my  instruments  in  several  packages,  and 
for  this  purpose  I  make  use  of  a  number  of  canvas  containers  of 


General  preparations  31 

different  sizes  with  a  list  of  the  instrnments  that  go  in  each 
package  printed  on  the  inside,  so  that,  in  gathering  together  what 
is  needed  for  any  particular  proeednre,  there  is  little  chance  of 
leaving  ont  anything  that  ma}^  be  required.  The  arrangement  is 
distinctively  neat  and  orderly.  The  craniotomy  instruments, 
for  example,  are  put  in  one  package,  the  forceps  in  another,  the 
suturing  material  in  another,  and  so  on.  Half  a  dozen  such 
packages  may  be  put  in  a  medium-sized  leather  satchel. 

The  following  lists  include  all  the  instruments  that  will  be 
needed  in  any  obstetric  operation: 

1  obstetric  forceps. 

1  Naegele  perforator. 

1  Gessner  or  Zweifel  cranioclast. 

1  Mesnard-Stein   boue   forceps. 

1  Braun  decapitation  hook. 

1  Siebold  decapitation  shears. 

1  Smellie  blunt  hook. 

1  Bunge  sling-carrier  and  sling. 

1  Leavitt  metal  dilator. 

1  scalpel. 

2  bullet  forceps. 

2  vulsellum  forceps  for  cervix. 
4  to  8  artery  forceps. 
1  needle-holder. 

1  surgical  tissue  forceps. 

2  pair  scissors,  small  and  large. 
1  abortion  forceps. 

1  abortion  curette. 

1  vaginal  speculum  ^Yith  large  plates. 

2  retractors. 

1  cylindrical  speculum. 

1  uterine  dressing  forceps. 

1  puncturing  metal  catheter. 

1  metal  urethral  catheter. 

1  gum  catheter. 

1  metal  bougie  for  artificial  induction  of  labor. 

1  box  surgical  needles. 

2  hydrostatic  dilators,  one  large  and  one  small. 
1  colpeurynter. 

1  100-gram  metal  sj'ringe. 

1  yard  of  red  gas  tubing. 

1  infusion  outfit. 

1  hypodermic  syringe. 

1  graduated  irrigator  with  tubing  and  glass  jioints. 


32  THE   SURGICAL   PROCEDURES 

1  nail  file. 

1  nail  clipper. 

2  liaiul  lirnshes. 

1  yard  sterile  iodoform  gauze  in  glass  jar. 

2  jars  antiseptic  gauze,  several  yards  each. 

1  Breisky  pelvimeter. 

2  tracheal  catheters  or  other  device  for  aspirating 

the  larynx. 
1  stethoscope. 
1  thermometer. 
1  steel  tape. 
1  chloroform  outfit. 
1  bottle  of  lysol. 
1  bottle  of  alcohol. 
1  tube  of  corrosive  siiblimatc  tablets. 
1  bottle  of  ergotin. 
1  bottle  of  camphorated  oil. 
6  ampules  of  pituitary  extract   (1/4  e.c). 
6  ampules  of  Iniiodermic  preparation  of  veratrum. 
1  tube  hyoscine-morphine  tablets  (^^on  g'l'-  hyos. 

and  y^  gr.  morph.). 
sterilized  catgut, 
silkworm  gut. 

3  pairs  of  rubber  gloves,  dry-sterilized  and  -wrapped 

in  gauze. 
1  operating  suit  (coat,  trousers,  and  gown). 
1  rubber  apron. 
To  this  list  may  be  added: 

1  axis  traction  forceps. 
1  trephine. 
1  breech  hook. 

1  pubiotomy  needle. 

2  wire  saws  with  handles. 

The  Preparation  and  Care  of  Instruments. — All  instruments 
must  be  boiled  for  eiglit  or  ten  minutes  immediately  before  using. 
The  addition  of  soda  to  the  water  preserves  their  nickel-plating. 
If  one's  outfit  includes  a  sterilizer,  the  preparation  of  instru- 
ments is  somewhat  simplified;  otherwise,  one  Avill  need  to  im- 
provise from  the  kitchen  utensils  a  suitable  bake-pan  in  which 
to  boil  them.  The  wash-boiler,  perhaps,  has  been  pressed  into 
service  oftenest,  and,  indeed,  it  answers  the  purpose  well. 

The  instruments  and  other  articles  to  be  disinfected  are  se- 
curely wrapped  in  one  or  more  towels,  tied  with  a  stout  cord, 
and  dropped  into  the  boiler.     The  cord  should  be  long  enough 


GENERAL   PREPARATIONS  33 

to  hang  outside,  so  that,  later,  the  packages  may  be  drawn  out 
and  deposited  in  a  bowl  of  cold  1  per  cent  lysol  solution  without 
danger  of  scalding  the  hands.  This  may  be  done  by  anyone  who 
happens  to  be  present,  but  the  opening  of  the  package  and  the  fur- 
ther handling  of  the  towel  and  instruments  must,  of  course,  be 
done  only  by  the  operator  or  other  jDroperly  disinfected  persons. 

All  water  that  is  used  for  cooling  solutions  or  instruments 
must  be  sterile.  Some  hours  before  it  will  be  needed,  one  or 
m.ore  granite-iron  pitchers  are  filled  with  clean  water,  covered 
with  a  clean  towel,  and  boiled  in  the  wash-boiler  for  twenty 
minutes.  The  pitchers  are  then  taken  out,  and  set  aside  to  cool. 
Their  further  handling  should  be  supervised  by  the  physician 
or  his  trusted  nurse. 

Immediately  after  the  operation  is  finished,  the  instruments 
should  be  cleaned  and  dried;  and,  before  arranging  them  in  the 
satchel  or  putting  them  in  the  cabinet,  they  should  again  be 
boiled  and  wiped  thoroughly.  Such  care  is  worth  while;  other- 
Avise,  instruments  become  tarnished  and  rusty. 

Suture  Material, — Silk  and  catgut  are  the  materials  most  com- 
monly employed  for  suturing.  Silk  may  be  sterilized  either  by 
steaming  or  boiling  at  the  time  of  operation,  but  catgut  can  not 
thus  be  treated,  and  must  be  prepared  in  other  ways.  Of  the 
two,  silk  is  the  more  reliable.  Silkworm-gut,  for  the  main,  is  the 
suture  material  best  calculated  to  hold  the  deeper  lesions  in 
juxtaposition,  but,  of  necessity,  has  to  be  taken  out  afterward. 
Catgut  is  reliably  prepared  in  various  sizes  and  lengths,  and 
preserved  in  sealed  glass  tubes.  To  prevent  its  too  rapid  disin- 
tegration, it  is  first  hardened  with  chromic  acid  or  formaline. 
But  there  is  always  some  danger  of  catgut  giving  way,  so  that, 
if  one  would  be  sure  of  holding  together  a  ruptured  perineum, 
it  is  well  to  introduce  at  least  one  deep  suture  of  silkworm. 

Dressing's. — For  dressings  one  should  be  supplied  with  sterile 
gauze  put  up  in  aseptic  form  and  in  suitable  quantities  for  im- 
mediate use,  gauze  sponges,  gauze  strips  for  packing  the  uterine 
cavity,  larger  pieces  for  tamponing  the  vagina,  etc.  Securely 
wrapped  and  pinned,  as  they  come  from  the  autoclave,  they  may 
be  carried  in  the  satchel  without  fear  of  contamination.  Some 
surgeons  prefer  iodoform  gauze,  and,  for  certain  purposes,  it 
may  have   advantages;   but,   on   account   of  its   distinctive   and 


o^  THE    SURGICAL   PROCEDURES 

penetrating  odor,  many  surgeons  will  not  use  it.  The  effect  of 
iodine  in  obstetrics  may  be  secured  l3y  other  and  less  offensive 
means:  for  example,  if  one  choose  to  pack  the  uterus  with  iodized 
gauze,  he  may  do  so  by  moistening  a  strip  of  plain  gauze  just 
before  its  introduction  with  the  tincture  of  iodine. 

ANESTHESIA 

Chloroform  Narcosis. — Chloroform  narcosis  in  childbirth  is 
remarkably  easy  to  induce;  the  patient  can  be  kept  sufficiently 
under  its  influence  to  admit  of  all  the  noncutting  operations  if 
only  a  few  drops  per  minute  be  given.  There  are  other  reasons 
for  recommending  chloroform  in  obstetrics.  After  its  conclusion 
the  patient  is  brought  quickly  back  to  consciousness;  it  is  fol- 
lowed by  almost  no  bad  after-effects,  and  it  is  assimilated  and 
eliminated  with  great  rapidity.  Several  drops  dashed  upon  the 
inner  surface  of  the  mask,  and  applied  to  the  patient's  nose  at 
the  beginning  or  just  before  the  onset  of  each  pain,  will  be  suf- 
ficient to  keep  her  in  a  semiconscious  state.  This  way  of  giving 
chloroform  may  be  continued  throughout  the  second  stage  of 
labor,  not  altogether  to  relieve  pain,  but  quite  as  much  to  cheek 
the  contractions,  especially  of  the  abdominal  muscles,  which 
sometimes  are  undesirablj^  active.  A  little  less  speed  permits 
relaxation  of  the  soft  tissues  and  thereby  preserves  the  integrity 
of  the  parts  which  otherwise  might  be  severely  lacerated. 

Deep  anesthesia,  of  course,  is  necessary  when  performing 
operations  that  require  perfect  relaxation  of  the  patient,  for, 
obviously,  she  must  be  quiet  during  such  procedures.  To  under- 
take an  important  manipulation  while  the  patient  is  only  par- 
tially anesthetized,  is  a  mistake.  One  had  better  give  none  at 
all  than  allow  only  enough  to  destroy  the  patient's  self-control. 
So  important  is  narcosis  under  such  circumstances  that  one 
ought  never  willingly  to  undertake  to  do  both, — perform  the 
operation  and  give  the  anesthetic, — without  proper  assistance. 
If  it  so  happens  that  he  must  proceed  without  such  help,  he  first 
disinfects  himself  and  the  patient,  prepares  whatever  may  be 
needed  in  the  operation,  draws  on  a  pair  of  rubber  gloves,  and, 
with  the  woman  lying  crossAvise  on  the  bed,  begins  the  anesthe- 
sia.    As  soon  as  she  is  well  under  its  influence,  the  chloroform 


GENERAL   PREPARATIONS  35 

bottle  and  mask  are  turned  over  to  the  husband,  or  someone 
else  pressed  into  service.  The  operator  then  removes  his  gloves, 
rubs  his  hands  again  with  alcohol,  draws  on  a  fresh  pair  of 
gloves,  and  proceeds  to  operate.  Meanwhile  he  watches  the 
respiration  of  his  patient,  and  otherwise  supervises  the  anesthe- 
sia. It  is  difficult,  even  risky,  to  undertake  such  procedures 
alone.  But  in  the  practice  of  obstetrics,  more  than  in  any  other 
field,  one  is  confronted  with  emergencies  that  must  be  dealt 
with  at  once  and  without  competent  help. 

Ether  in  Labor. — Ether  in  labor  is  recommended  when  nar- 
cosis is  prolonged,  or  the  heart  is  affected.  It  is  also  safer  to 
administer  than  chloroform  in  conditions  of  severe  anemia. 

Twilig-ht  Sleep. — The  narcosis  produced  by  a  combination  of 
scopolamine  and  morphine  is  d-eserving  of  passing  consideration. 
Given  hypodermically,  it  produces  a  peculiar  aberration  of  mind 
that  appeals  to  some  women  very  strongly.  For  many  years  this 
method  of  securing  painless  childbirth  has  been  practiced  in 
Freiburg,  but  not  until  recently  was  public  attention  called  to 
it  in  this  country.  Through  several  of  the  popular  magazines 
millions  have  read  of  ''twilight  sleep,"  until  now  there  have 
developed  organizations  of  lay  women  who  demand  it,  willy- 
nilly.  The  usual  dose  is  in  the  proportion  of  %  to  14  gi'-  of  mor- 
phine to  1/200  to  1/100  gr.  of  scopolamine  (hyoscine),  the  latter 
drug  alone  to  be  repeated  at  intervals  of  from  one  to  three  hours. 
As  a  result  of  this  publicity,  obstetricians  have  been  experi- 
menting with  various  drugs,  hoping  to  find  some  better  means  of 
assuaging  the  suffering  of  childbirth  than  they  already  possess. 
Until  some  standardization  has  been  obtained,  it  is  thought  wise 
at  this  time  to  postpone  a  more  lengthy  discussion  of  the  subject. 
Generally  speaking,  the  author  is  of  the  opinion  that  art  still 
has  a  long  way  to  go  before  it  can  catch  up  with  nature;  and, 
after  all,  do  not  all  the  processes  of  life  have  within  themselves 
the  needful  compensation  of  action  and  reaction? 

Spinal  Anesthesia. — Spinal  anesthesia  has  a  very  limited  use 
in  obstetrics.  Painlessness  can  be  induced  by  it,  but  the  reflexes 
are  not  always  abolished.  It  has  been  recommended  in  repairing 
the  more  severe  lacerations  accompanying  delivery.  The  technic 
is  as  follows:  The  skin  area  surrounding  the  point  of  injection 
is  disinfected;  the  intersjpace  between  the  spinous  processes  of 


36  THE   SURGICAL   PROCEDURES 

the  second  and  third  himhar  verteljra3  located,  the  patient  sitting 
in  a  bent  over  posture;  a  tine  trochar  is  pushed  through  the 
skin  in  the  center  of  the  space ;  the  obturator  withdrawn,  and  the 
hollow  needle  pushed  farther  in.  As  soon  as  the  spinal  canal  is 
entered  fluid  will  l^egin  to  run  from  the  needle.  After  a  suffi- 
cient amount  of  fluid  has  been  removed,  a  prepared  solution  of 
novocaine  is  injected.  It  takes  about  five  minutes  for  the  anes- 
thesia to  act.  It  is  sometimes  difficult,  particularly  in  fat  women, 
to  carry  the  needle  into  the  spinal  canal;  the  vertebrae  may  of- 
fer obstruction,  or  the  needle  itself  may  become  occluded  with  a 
small  clot  of  blood.  Such  interferences  will  reciuire  maneuver- 
ing, the  needle  being  partly  withdravni  and  redirected  half  a 
centimeter  higher  or  lower.  The  sharp-pointed  obturator  should 
be  passed  into  the  needle  in  making  these  excursions. 

ASSISTANCE 

The  more  important  obstetric  operations  ought  never  to  be 
performed  without  competent  assistance;  yet  it  will  happen 
occasionally,  especially  in  country  practice,  that  the  obstetrician 
comes  face  to  face  Avitli  emergencies  that  must  be  dealt  with  at 
once,  and  single-handed.  It  is  at  such  times  that  judgment 
serves  us  well  if  we  refrain  from  attempting  operations  that  can 
safely  be  deferred  until  sufficient  help  arrives;  but,  if  we  do 
undertake  them,  we  should  stop  long  enough  to  plan  carefully 
every  step  that  is  to  be  taken  before  exhibiting  our  intrepidity. 


CHAPTEE  II 
INDICATIONS  AND  CONDITIONS 

Normal  childbirth  is  a  physiologic  process.  This  fact  should 
always  be  borne  in  mind  by  the  physician.  The  process,  however, 
is  so  often  complicated  that  the  transition  from  a  normal  to  a 
I)athologic  state  is  not  easily  discerned.  Conditions  arise  in  the 
space  of  a  moment  which  may  throw  both  mother  and  child  into 
great  danger.  With  this  possibility  in  view,  it  rests  with  the 
obstetrician  ever  to  be  ready  with  skill  and  experience  to  man- 
age successfully  any  abnormal  condition  that  may  threaten  the 
life  of  his  patient.  It  depends  on  him  to  command,  to  regulate, 
to  advise,  to  encourage,  and,  eventually,  perhaps,  to  operate, 
that  danger  may  be  averted. 

In  considering  what  must  be  done  in  the  presence  of  danger, 
one  should  never  forget  that  two  lives  are  to  be  safeguarded, 
and  that  ideal  obstetrics  contemplates  the  saving  of  both  mother 
and  child.  If,  as  sometimes  happens,  the  safety  of  one  or  the 
other  must  be  risked,  the  mother's  life,  generally  speaking,  is 
counted  to  be  more  precious  than  that  of  the  child.  After  reflect- 
ing on  the  situation  before  him,  the  conscientious  physician 
should  ask  himself  fairly  and  squarely  two  questions:  Am  I 
jeopardizing  a  life  if  I  do  the  thing  that  suggests  itself?  And 
am  I  qualified  to  do  this  particular  piece  of  work?  So,  in  the 
study  of  indications  and  preliminary  conditions,  the  obstetrician 
should  know  the  signs  of  danger,  and  should  recognize  them 
quickly;  he  should  be  prepared  to  act  promptly;  and,  above  all, 
he  must  be  master  of  the  situation, 

DANGERS  TO  THE  MOTHER 

Women  in  pregnancy  are  not  exempt  from  intercurrent  affec- 
tions. In  themselves,  such  diseases  may  become  dangerous,  but 
they  are  not  necessarily  made  so  by  the  process  of  child-bearing ; 
nor,  on  the  other  hand,  is  pregnancy  and  labor  always  seriously 

37 


38  THE   SURGICAL   PROCEDURES 

affected  by  intercurrent  disease.  A  woman  may  be  suffering, 
for  example,  from  a  severe  injury  to  the  eye,  or  from  a  malig- 
nant tumor  of  the  breast,  or  even  from  an  acute  infection,  and 
may,  therefrom,  find  herself  in  danger;  yet  these  ailments  can 
in  no  way  be  said  to  arise  from  her  condition,  nor  will  parturi- 
tion in  the  least  influence  their  course. 

Internal  Affections. — Affections  which  of  themselves  have  no 
relation  to  pregnancy,  may  yet  be  so  unfavorably  influenced  by 
it  that  it  will  be  found  expedient  or  even  necessary  to  interrupt 
the  pregnancy,  and  hasten  delivery.  This  holds  true  more  par- 
ticularly in  diseases  of  the  respiratory  and  circulatory  organs. 
Pregnancy  complicated  with  pneumonia  or  advanced  laryngeal 
or  i3ulmonary  tuberculosis,  makes  such  demands  on  the  organs 
involved  that  an  irreparable  aggravation  of  the  disease  or  even 
death  may  supervene.  Compensatory  changes  in  the  heart,  as 
well,  are  influenced  unfavorably  by  pregnancy  and  labor.  Not 
only  the  pain  of  labor  itself,  but  the  variations  in  blood  pres- 
sure which  accompany  labor,  involve  to  a  marked  degree,  and 
dangerously,  the  noncompensated  lesion.  Under  such  circum- 
stances the  obstetric  indication  should  be  to  interfere  and  cut 
short  the  pregnancy;  otherwise,  jirolongation  of  the  unbalanced 
forces  might  result  disastrously. 

Puerperal  Infection. — Dangers  which  arise  from  the  activities 
of  birth  itself  and  which  disappear  when  labor  is  over,  constitute 
other  and  i)roper  indications  for  interference.  Such  dangers 
can  appear  at  any  stage  of  labor,  and  in  every  degree  of  severity. 
Extraction  with  forceps,  craniotomy,  pubiotomy,  and  cesarean 
section  are  some  of  the  procedures  which  one  is  called  upon  to 
undertake. 

An  elevated  temperature  during  labor  does  not  necessarily 
mean  p  genital  infection.  It  may  be  due  to  any  acute  disease, 
such  as  typhoid  fever;  and  even  prolonged  labor  itself,  through 
muscular  activity,  can  raise  the  body-heat  several  degrees.  Such 
a  fever  does  not  always  call  for  interference.  But  an  intrapar- 
tum fever  may,  hoAvever,  become  a  grave  pathologic  symptom  of 
genital  infection,  one  Avhich  could  cause  death  of  both  the 
mother  and  child  before  labor  is  over.  Particularly  in  long 
labors,  if  frequent  vaginal  examinations  have  been  made,  the 
introduction  of  microorganisms  into  the  fruit  sac  becomes  easy. 


INDICATIONS    AND    CONDITIONS  39 

Even  with  the  amnion  intact  this  is  not  impossible,  especially 
since  fingers  and  instruments  so  readily  implant  them  on  the 
membranes.  Also  in  the  sac  itself  are  to  be  found  microorgan- 
isms, the  virulence  of  which  depends  on  the  decomposing  liquor 
amnii  and  its  resulting  toxin.  Through  extension,  which  is  an 
inherent  invasive  quality  of  microorganisms,  they  may  reach,  in 
due  time,  the  uterine  tissues,  where  they  remain  to  carry  on  their 
destructive  work.  The  symptoms  thereby  developed  are  fever, 
increased  pulse  rate,  chills,  offensive  discharges,  and,  under  cer- 
tain circumstances,  putrid  gases  in  the  uterus.  These  variations 
from  the  normal  go  to  make  up  the  symptom-complex  of  infec- 
tion, the  importance  of  which  should  not  be  overlooked.  They 
Vv^ill,  however,  escape  attention  if  the  physician  fails  to  make 
occasional  observations  of  both  pulse  and  temperature. 

A  disturbance  of  the  pulse  is  frequently  the  first  sign  of 
infection,  showing  itself  early,  even  preceding  the  rise  in  tem- 
perature ;  indeed,  so  reliable  a  sign  is  it  that  one  may  look 
upon  an  increased  pulse  rate  in  a  prolonged  labor  as  strong 
evidence  of  infection.  It  should  be  noted  in  this  connection 
that  the  pulse  rate  can  also  be  increased  in  the  anemic  states, 
and  that  it  is  susceptible  to  psychic  stimuli,  such  as  the  arrival 
of  the  physician,  the  apprehensive  bearing  of  those  about  the 
patient,  etc. 

The  appearance  of  chills  is  also  of  evil  omen,  and  points  to 
the  introduction  of  bacteria  or  toxins  into  the  vascular  system. 

The  foul-smelling  discharge  which  comes  from  the  vagina,  and 
which  may  be  perceived  on  the  examining  finger,  is  due  to 
local  decomposition  going  on  within  the  uterus.  This  may  be 
obscured  if  the  advancing  part  of  the  fetus  so  closely  occludes  the 
birth  canal  that  none  of  the  offensive  secretion  can  escape,  and 
will  unmistakably  announce  itself  only  when  the  child  is  born. 
However,  should  the  obtruding  part  be  forced  back  by  the  ex- 
amining hand,  or  be  lifted  with  a  blade  of  the  forceps,  the  fluids 
run  out  at  once,  and  the  decomposing  gases  escape.  This  ac- 
cumulated gas  is  itself  of  saprophytic  formation.  In  rare  cases 
it  may  come  fi'om  the  colon  bacillus,  AA-hich,  in  the  presence  of 
sugar,  also  forms  gas.  The  inflation  produces  a  tympany  of  the 
uterus  which  m.ay  be  demonstrated  by  percussion ;  but  one  should 


40  THE    SURGICAL   PROCEDURES 

recall  the  possibility  of  an  overlying  flatulent  intestine,  and 
not  mistake  it  for  the  percussion  phenomenon  of  tympanites  uteri. 
In  all  conditions  of  infection  it  is  Avell  to  let  labor  take  its  own 
course,  for  it  has  been  observed  that,  in  terminating  the  birth 
speedily,  infectious  material  is  set  free  from  the  uterus,  and 
more  readily  finds  its  way  into  the  circulation.  Such  infections 
are  not  always  disastrous,  by  any  means.  "VVe  know  that  in 
many  instances  intrapartum  troubles  of  this  sort  are  unaccom- 
panied by  harm  to  either  mother  or  child.  Yet  one  is  not  always 
in  a  position  to  know  whether  he  is  dealing  with  a  mild  or  a 
severe  infection,  and,  before  undertaking  to  end  the  birth  by 
operative  procedure,  he  should  give  due  consideration  to  every 
appearance  of  sepsis;  and  he  should  realize  that  energetic  inter- 
ference, especially  during  the  earlier  stages  of  labor,  is  likely 
to  be  accompanied  by  lesions  which  offer  inviting  surfaces  for 
inoculation.  Consequently,  one  ought  to  refrain  from  such 
activity  until  after  the  cervix  has  been  fully  dilated,  when  the 
indicated  operation  may  be  carried  out  with  relative  safety. 
Version,  for  obvious  reasons,  is  one  of  the  procedures  that 
should  be  avoided,  since  by  entering  the  uterus  with  the  hand 
a  general  smearing  of  its  cavity  with  pyogenic  germs  is  sure  to 
occur.  If  immediate  delivery  be  indicated,  it  is  safer  to  take  the 
child  as  it  lies,  either  by  forceps,  extraction  by  the  breech,  or, 
possibly,  by  perforation  and  cranioelasis. 

Eclampsia. — While  the  etiology  of  eclampsia  is  somcAvhat  ob- 
scure, it  is  sufficiently  clear  to  warrant  certain  conclusions  con- 
cerning it.  A  series  of  hypotheses  have  been  developed  which 
go  to  prove  that  certain  products  coming  from  the  embryo  find 
lodgment  in  the  maternal  organism.  These  products,  whatever 
they  may  be,  are  not  counteracted  or  eliminated  by  the  mother's 
tissues,  and  their  augmentation  reaches  a  point  of  toxicity  which 
may  burst  forth  in  the  form  of  convulsions.  That  the  embryo 
is  the  source  of  such  poisoning,  is  founded  on  the  observation 
that  the  condition  is  at  once  relieved  if  the  embryo  perish  or  is 
removed  from  the  mother.  The  manner  of  treating  eclampsia, 
as  carried  out  in  different  clinics,  also  tends  to  confirm  this 
hypothesis.  A  compilation  of  statistics  from  all  parts  of  the 
country  shows  a  mortality  of  about  25  per  cent.     Comparing  the 


INDICATIONS    AND    CONDITIONS  41 

statistics  of  some  of  the  most  reliable  clinics  of  Germany  with 
these  figures,  it  is  shown  that,  while  the  climes  abroad  have  the 
more  severe  cases  to  deal  with,  their  mortality  rate  is  consider- 
ably lower.  Contrasting,  for  example,  the  percentage  obtained 
in  the  province  of  East  Prussia  with  that  of  the  Koenigsberg 
and  Berlin  clinics,  the  proportion  is  25  per  cent  in  the  one  to 
17  per  cent  in  the  other.  This  difference  is  believed  to  be  due 
to  the  fact  that  in  Berlin  and  Koenigsberg  eclampsia  is  treated  by 
immediate  delivery.     (See  chapter  on  Eclampsia,  page  398.) 

General  Exhaustion. — Not  only  does  the  woman  in  labor  suf- 
fer from  loss  of  sleep  and  insufficient  nutrition,  but,  through  the 
contractions  of  the  uterus,  the  activity  of  the  abdominal  muscles, 
and  the  exertion  of  her  entire  body,  she  becomes  fatigued  and 
sometimes  exhausted.  Add  to  these  tests  of  endurance  the 
psychic  influences  that  surround  her,  such  as  the  uncertainty  of 
the  outcome,  the  apprehension  of  complications,  the  excitement 
of  preparation,  and  the  dread  of  painful  examinations,  and  there 
is  little  wonder  that  a  woman  in  labor  should  be  overcome.  Nor 
is  it  always  the  frail  individual  who  first  succumbs  to  exhaus- 
tion, for  oftentimes  there  resides  in  the  weak  organism  an 
energy  and  will  more  enduring  than  mere  bodily  strength. 

It  is  not  easy,  by  any  means,  to  determine  the  degree  of  ex- 
haustion. The  apparent  lack  of  progress,  the  impatience  mani- 
fested by  the  patient  that  birth  should  move  so  slowly,  the  air 
of  criticism  because  the  doctor  does  not  "do  something,"  all 
tend  to  intensify  the  element  of  fatigue,  and  engender  the  wish 
for  a  speedy  termination  of  labor.  And  right  here  is  one  of  the 
most  dangerous  pitfalls  in  the  practice  of  obstetrics.  Pleaded 
with  by  the  patient,  and  encouraged  by  the  relatives  to  inter- 
pose, one  is  sometimes  overpersuaded,  and  does  the  thing  he 
ought  not  to  do — interfere.  Even  the  most  conservative  of  prac- 
titioners will  recall  instances  in  his  experience  Avhen  operative 
measures  were  attended  by  ill  effects  because  of  their  untimely 
application.  That  such  mistakes  may  be  avoided,  one  should 
study  closely  objective  rather  than  subjective  signs  of  exhaus- 
tion. Nor  should  one  overlook  the  psychic  influence  in  combat- 
ing fatigue.  By  advising,  encouraging,  and,  perhaps,  l)y  com- 
manding, the  suffering  woman's  fortitude  will  be  strengthened, 


42  THE    SURGICAL   PROCEDURES 

and  labor  again  will  resume  its  natural  course.  It  often  works 
well  to  give  an  anodyne  like  morphine,  alone  or  in  combination 
with  atropine  or  hyoscine.  A  few  hours  of  sleep  and  rest  gained 
by  it  act  as  a  restorative.  Afterward  she  will  go  on  with  her 
labor  with  renewed  energy. 

All  such  measures  may  occasionally  prove  of  no  avail,  and 
yet  one  is  hardly  justified  in  resorting  to  operative  procedure 
unless  labor  is  well  advanced.  When  cervical  dilatation  is  com- 
plete, liirtli  may  be  concluded  without  occasioning  much,  if  any, 
harm  by  the  application  of  forceps,  or  an  extraction  by  the 
breech. 

There  is  one  condition  that  should  be  mentioned  which  has 
the  appearance  of  exhaustion,  but  which  really  is  one  of  prostra- 
tion ;  it  is  due  to  a  severe  infection.  In  it  the  failing  forces  mani- 
fest themselves  very  early  and,  under  certain  circumstances, 
become  so  serious  that  labor  ceases  before  delivery  is  complete. 
Such  a  condition  ought  never  to  be  mistaken  for  a  simple  exhaus- 
tion. In  the  one  the  temperature  and  pulse  remain  undisturbed, 
and  the  general  state  of  the  patient  is  quiet,  in  the  other  the 
temperature  is  high,  the  pulse  frequent  and  small,  the  patient 
grows  extremely  restless,  and  the  whole  appearance  is  one  of 
infection. 

Weakness  of  the  Uterine  and  Abdominal  Forces. — In  order 
that  labor  may  go  on  satisfactorily,  certain  general  and  local 
conditions  are  essential.  The  entire  organism  must  possess  a 
certain  degree  of  strength;  the  uterine  walls  must  be  sufficiently 
thick;  the  musculature  peculiarly  adapted  to  the  occasion;  and 
lodged  somewhere  therein  must  abide  that  mysterious  something, 
which  controls  the  object  and  purpose  of  birth.  The  efficiencv 
of  abdominal  pressure  must  also  be  taken  into  account,  includ- 
ing the  development  of  accessory  muscles,  the  diaphragm,  and 
the  levator  ani.  Together  they  form  an  integral  boAv  that  comes 
into  play  at  the  height  of  uterine  contraction.  The  will  power 
of  the  patient  can,  to  a  certain  degree,  influence  this  pressure 
cither  to  increase  or  decrease  its  force. 

Inertia. — "Weakness  of  the  patient  may  exist  from  the  very 
beginning  of  labor,  when  it  is  spoken  of  as  primary  inertia ;  or 
it  may  manifest  itself  in  a  later  stage,  when  it  is  called  secondary 


INDICATIONS    AND    CONDITIONS  43 

inertia.  The  primary  form  is  usually  due  to  a  general  debility 
of  tlie  individual,  who  may  be  suffering  from  a  wasting  disease. 
Likewise  a  number  of  particularly  severe  labors  in  rapid  succes- 
sion may  bring  about  the  same  lack  of  strength.  There  may 
also  be  local  causes  of  weakness,  esi^ecially  undevelopment  of 
the  uterus,  to  be  observed  in  the  very  young  and  very  old 
primiparse. 

If  the  uterus  becomes  overdistended,  as  in  twin  pregnancy 
and  in  hydramnioii,  the  muscle  wall  becomes  thin,  and  loses 
much  of  its  contractile  power;  or  if  the  wall  of  the  uterus  be- 
comes more  or  less  replaced  by  a  new  growth,  a  myoma  for 
example,  its  functioning  power  will  be  lessened,  and,  in  like 
manner,  may  cause  inertia.  Marked  overdistention  of  the  blad- 
der and  rectum  may  similarly  have  an  unfavorable  action  on 
labor. 

Secondary  inertia,  on  the  other  hand,  makes  its  appearance  in 
the  later  stages  of  labor,  mostly  during  the  expulsive  period. 
It  is  due  mainly  to  the  tiring-out  of  the  uterus,  which  is  made 
worse  if  at  some  point  along  the  birth  canal  an  abnormal  resist- 
ance has  to  be  overcome.  The  most  common  obstructions  are  of 
the  soft  parts  and  of  the  pelvis,  though  an  abnormally  large 
head  that  will  not  engage,  or  a  faulty  presentation  of  the  fetus 
may  give  rise  to  the  same  trouble.  Insufficient  action  of  the 
accessory  forces  may  be  at  fault ;  or  it  may  be  that  these  forces 
themselves  have  become  tired  out  from  inopportune  et¥orts  to 
expel  the  fetus.  Women  in  labor  are  anxious  to  be  over  the 
ordeal,  and,  naturally,  listen  to  advice  that  offers  promise  of 
early  relief.  Misunderstanding  the  timelessness  of  such  en- 
couragement, they  "bear  down"  too  early  only  to  find  themselves 
spent  when,  later,  the  proper  time  comes  to  make  use  of  their 
reserve  strength.  Another  and  quite  opposite  effect  is  some- 
times observed  when  at  the  height  of  a  contraction,  dreading  the 
intensified  pains  of  expulsion,  the  patient  tries  to  check  it  by 
''holding  back."  A  deficient  formation  of  the  abdominal  group 
of  muscles,  "paunch  bellies,"  and  walls  that  have  been  dis- 
tended by  many  pregnancies  are  also  quite  important  factors 
in  inertia. 

AH  these  disturbances  have  the  same  effect, — they  interfere 


44  THE    SURGICAL   PROCEDURES 

■with  the  progress  of  labor  and  eventually  stop  the  process.  The 
condition  is  not  dangerous  to  the  mother  or  the  child,  except  the 
sac  be  ruptured  and  labor  comes  to  a  standstill;  then  there  is  a 
possibilitj^  of  microorganisms  finding  their  way  into  the  cavity 
and  doing  much  harm. 

Treatmelit  of  Inertia. — In  contending  vith  inertia,  our  first 
object  should  be  to  restore,  if  possible,  the  normal  activities  of 
labor.  This  is  not  always  easy,  for  we  possess  no  therapeutic 
measure  which  will  promptly  and  certainly  regulate  uterine  con- 
traction. But  there  are  a  number  of  remedies  worth  trying. 
Heat,  for  instance,  has  a  favorable  action  on  the  uterus,  and, 
when  used  in  the  form  of  fomentations,  has  often  proved  effective 
in  rekindling  the  extinguished  energies.  Occasionally,  alternat- 
ing the  hot  with  cold  compresses  acts  even  better.  More  active 
still  are  hot  vaginal  douches,  given  at  a  temperature  of  120  to 
140  degrees,  and  directed  to  the  vault  of  the  vagina.  The 
douches  may  be  repeated  in  an  hour,  but  the  treatment  is  not 
entirely  without  ill  effect,  because  of  the  damage  such  hot  lo- 
tions do  to  the  mucous  membrane.  The  colpeurynter,  or  vaginal 
rubber  balloon,  introduced  into  the  vagina  and  distended,  is  an- 
other means  of  evoking  the  pains  of  labor.  A  still  more  ef- 
fective device  is  the  metreurynter,  or  uterine  bag.  It  is  non- 
elastic,  and  its  introduction  into  the  uterus  stimulates  contrac- 
tion, especially  if  a  little  traction  be  made  as  it  lies  distended 
in  the  lower  segment.  It  should,  however  be  employed  only 
when  specially  indicated  and  not  merely  to  correct  simple  pri- 
mary inertia. 

Internal  remedies  have  met  with  some  measure  of  success; 
and,  so  long  as  they  are  relatively  safe,  may  be  used.  For  the 
most  part  quinia  has  been  approved.  It  is  given  in  ten-grain 
capsules  every  hour  for  three  hours.  One  can  hardly  believe 
that  sugar  or  any  comparable  substance  can  have  therapeutic 
value  except  as  it  may  act  through  the  mind ;  but  since  no  harm 
can  come  from  it  there  can  be  no  serious  objection  to  its  use  as  a 
vehicle  for  psychotherapy.  Ergot  and  the  newer  drug,  pituitary 
extract,  Avhatever  may  be  claimed  for  them,  should  not  be  given 
in  the  early  stages  of  labor.     They  are  used  to  cause  a  tonic 


INDICATIONS   AND    CONDITIONS  45 

contraction  of  the  uterine  muscle,  which  is  not  to  be  desired  at 
this  time. 

If  inertia  is  due  to  overdistention  of  the  uterus,  as  from  twins 
and  hvdramuion,  tlie  memln-anes  should  be  ruptured.  The  organ 
then  becomes  smaller  and  better  able  to  contract. 

The  management  of  inertia  near  the  close  of  lal:)or  is  some- 
what different  from  the  foregoing.  Inasmuch  as  there  is  no  im- 
mediate danger  from  arrested  birth,  interference  may  still  safely 
be  deferred.  The  simpler  measures  having  failed  to  relieve  the 
condition,  more  potent  remedies  should  be  tried.  Ergot  is  a 
most  powerful  oxytocic,  but  its  use  is  limited.  Pituitary  ex- 
tract, while  less  violent  in  its  action  than  ergot,  is  by  no  means  to 
be  given  indiscriminately.  At  the  present  time  it  is  perhaps  the 
most  frequently  employed  drug  for  accelerating  parturition  that 
was  ever  presented  to  the  medical  profession.  Judging  from 
the  freedom  with  which  it  is  given,  and  the  apparently  few 
instances  of  harm  following  its  use,  it  appeals  to  many  physi- 
cians; yet  there  are  those  who  condemn  it,  and  probably  not 
without  reason.  My  own  experiences  with  it  are  not  unfavor- 
able, and  I  have  resorted  to  it  on  many  occasions.  Indeed,  I 
may  say  that  when  timely  given  its  action  is  most  gratifying. 

Another  way  of  treating  fatigue  is  to  give  the  patient  artificial 
rest  with  morphine,  hypodermically.  Under  ordinary  circum- 
stances this  will  induce  several  hours  of  sleep,  and  labor  will 
begin  with  renewed  force.  Only  in  case  an  easy  delivery  may  be 
accomplished  with  forceps,  and  after  drugs  and  other  remedies 
have  failed,  is  its  use  to  be  encouraged.  The  procedure  may  be 
looked  upon  favorably  if  it  may  reasonably  be  supposed  that 
the  child  will  not  be  born  spontaneously;  or,  if  by  waiting,  other 
complications,  such  as  fever  of  the  mother  and  asphyxia  of  the 
child,  are  feared.  All  of  these  conditions  furnish  their  own 
indications  for  interference. 

DANGERS  TO  THE  CHILD 

Of  the  many  dangers  that  threaten  the  life  of  the  unborn  child, 
nearly  all  arise  from  the  same  cause,  a  disturbed  circulation 
between  the  fetus  and  the  mother.  It  all  culminates  in  the  fact 
that  the  amount  of  oxygen  held  and  carried  by  the  fetal  blood 


46  THE    SURGICAL   PROCEDURES 

becomes  abnormally  reduced.  This  comes  about  in  several  ways. 
The  reduced  state  of  the  mother's  blood,  for  one  thing,  has  a 
marked  effect,  in  that  the  total  quantity  of  available  oxygen  is 
lessened  thereby.  A  reduction  in  the  size  of  the  placental  area, 
as  may  occur  from  a  portion  of  it  becoming  loose,  will  also  help 
to  diminish  the  supply  of  blood  to  the  child.  The  same  thing 
can  happen  if  a  section  of  the  placenta  be  shut  off  through  de- 
generative change  or  through  the  presence  of  an  infarct.  A 
long-continued  labor  also  interferes  with  oxygenation  through 
condensation  of  the  placenta,  for  not  only  is  the  area  reduced  in 
size,  but  the  caliber  of  the  vessels,  particularly  those  of  the 
uterine  wall,  becomes  smaller.  The  umbilical  cord  itself  may 
suffer  pressure,  impeding  or  wholly  interrupting  the  circulation 
between  mother  and  child.  And,  lastly,  placental  circulation 
may  be  disturbed  indirectly  from  severe  and  uneciual  cerebral 
compression.  Even  if  the  child  be  born  with  a  few  flickering 
signs  of  life,  asphyxia,  by  its  destructive  influences,  has  so  af- 
fected the  vital  centers  or  so  injured  the  structure  of  the  lungs 
that  it  can  not  long  survive. 

The  following  affections  and  abnormalities  are  relatively  fre- 
quent and  especially  dangerous  to  the  child:  (1)  severe  anemia  of 
the  mother;  (2)  certain  respiratory  and  circulatory  diseases  of 
the  mother,  such  as  pneumonia  and  heart  affections;  (3)  eclamp- 
sia; (4)  premature  detachment  of  the  placenta;  (5)  prolonged 
labor  after  the  rupture  of  the  amniotic  sac,  particularly  in  the 
second  stage;  (6)  funic  complications, — low  position,  prolapse, 
knots,  coiling  about  the  body  of  the  child,  etc.;  (7)  severe  pres- 
sure on  the  child's  head;  (8)  breech  positions  with  delay  in  the 
delivery  of  the  head;  and  (9)  multiple  birth  after  the  first 
child  has  been  delivered. 

The  Sig-ns  of  Disturbed  Placental  Circulation 

The  Discharg-e  of  Meconium. — The  overloading  of  the  fetal 
blood  with  carbonic  acid  gas  has  an  irritating  effect  on  the  celiac 
plexus  and  splanchnic  nerve,  which,  in  turn,  stimulates  intestinal 
peristalsis  and  a  consequent  discharge  of  meconium  into  the  amni- 
otic fluid.  The  liquor  amnii  becomes  turbid  from  the  admixture, 
taking  on  a  greenish-yellow  appearance.     Such  evacuations  into 


INDICATIONS    AND    CONDITIONS  47 

the  amniotic  cavity  can  not  be  discovered  unless,  upon  examina- 
tion with  tlie  hand  or  the  introduction  of  a  forceps  blade,  the  oc- 
cluding head  be  dislodged  and  the  fluid  allowed  to  escape.  Meco- 
nium can  be  expressed  from  the  child  as  it  passes  through  the 
soft  parts  of  the  parturient  canal,  often  observed  in  breech  births, 
which  makes  it  probable  that  intraamnion  evacuations  may  occur 
from  causes  other  than  asphyxia.  At  any  rate,  the  discharge  of 
meconium  is  not  in  itself  an  indication  for  interference ;  it  is 
simply  a  warning  that  all  is  not  right.  The  fetal  heart  should 
be  closely  watched,  and  labor  terminated  if  asphyxia  becomes 
apparent. 

Variations  in  the  Fetal  Heart  Sounds. — An  important  symptom 
of  a  disturbed  circulation  is  the  variation  from  normal  of  the  fetal 
heart.  The  increased  carbonic  acid  gas  causes  an  irritation  of 
the  vagus  nerve  and  thereby  an  increased  activity  of  the  heart. 
The  average  number  of  pulsations  in  the  fetus  are  about  140  to 
the  minute,  but  it  may  vary  within  physiologic  limits  between 
120  and  160.  When  the  uterus  contracts,  its  own  vessels,  as  well 
as  those  of  the  placenta,  become  considerably  decreased  in  size, 
so  that  for  a  short  time  the  amount  of  oxygen  to  reach  the  child 
is  lessened.  The  effect  is  to  reduce  the  frequency  of  the  heart- 
beat. But  as  soon  as  the  pain  has  passed,  the  normal  rhythm  is 
again  restored ;  and  only  Avhen  in  the  interim  it  fails  to  do  so 
should  this  be  looked  upon  as  a  sign  of  asphyxia. 

Premature  Respiratory  Effort. — A  child  suffering  from 
asphyxia,  before  it  dies  from  lack  of  oxygen,  attempts  to  breathe 
while  yet  unborn.  In  its  struggles  for  breath,  not  only  the  respira- 
tory muscles  proper,  but  the  musculature  of  the  entire  body 
participates  in  the  convulsive  effort.  As  a  result  of  such  strenu- 
ous inspiratory  activity  the  bronchi  become  filled  with  fluid,  the 
blood  vessels  of  the  thoracic  cavity  become  congested,  and  even 
hemorrhage  and  punctiform  extravasations  of  blood  appear  in 
the  pleura  and  pericardium.  The  effort  to  breathe  may  be  strong 
enough  to  shake  the  abdominal  and  uterine  walls  of  the  mother ; 
and  in  breech-births,  after  the  buttocks  have  been  born,  these 
convulsive  movements  of  the  child  can  be  seen,  as  well  as  felt. 
It  follows,  then>  that  when  an  unborn  child  is  struggling  for 
breath,  something  must  be  done,  and  done  quickly,  or  it  will 
perish. 


48  THE   SURGICAL   PROCEDURES 

Preliminary  Conditions 

Every  operation  whose  aim  is  to  facilitate  delivery  presup- 
poses as  one  of  the  preliminarj^  conditions  a  sufficient  opening 
of  the  mother's  soft  parts,  especially  of  the  os  uteri,  for  the 
child  to  pass  through.  Only  when  these  parts  are  dilated  or 
dilatable,  can  the  object  be  accomplished  without  severe  injury. 
Hence,  it  is  absolutely  essential,  before  attempting  to  empty  the 
uterus,  that  an  exact  determination  as  to  this  condition  be  made 
by  examination. 

In  making  such  an  examination  it  is  quite  as  important  to 
find  out  the  state  of  the  internal  as  well  as  of  the  external  os, 
for  both  must  be  dilated  before  birth  can  take  place.  It  is  usual 
in  first  births  for  the  internal  os,  together  with  the  cervix,  to 
disappear  by  the  end  of  pregnancy.  By  almost  imperceptible 
degrees  this  portion  of  the  uterus  becomes  effaced,  so  that  when 
labor  actually  begins  only  the  external  os  remains  to  be  dilated. 
In  subsequent  pregnancies  the  condition  is  somewhat  different, 
the  inner  os,  for  the  most  part,  remaining  as  open  as  the  external; 
but  on  the  other  hand,  it  may  be  narrower  and  more  con- 
tracted. To  make  sure  of  the  condition  it  is  necessary  to  intro- 
duce a  part  or  even  the  whole  of  the  hand  into  the  uterine  cav- 
ity. Such  an  examination  is  rather  painful,  and  may  require 
an  anesthetic. 

Dilatation  of  the  cervix  is  said  to  be  complete  when  it  is 
open  enough  to  allow  the  head  of  the  fetus  to  pass  through 
it.  The  margin  of  the  os  can  not  then  be  felt  upon  exam- 
ination; it  will  have  been  drawn  back  over  the  head.  If 
the  presenting  part  remains  above  the  inlet,  as,  for  example,  in 
eross-births,  the  cervix  does  not  entirely  disappear,  though  it 
may  be  dilated  sufficiently  to  allow  the  child  to  pass.  A  tech- 
nical point  in  determining  whether  the  process  of  obliteration 
is  complete  or  not  is  to  see  if  the  pelvic  wall  can  be  reached  with 
the  fingers  while  applied  against  the  margin  of  the  external  os. 
If  this  can  be  done  without  occasioning  too  much  pain,  continue 
the  examination  by  introducing  the  fingers  into  the  cervix,  and 
note  the  distance  between  the  external  and  internal  parts  of  the 
canal.  In  like  manner  this  portion  also  may  be  pressed  against 
the  bony  pelvis  if  dilatation  is  sufficient. 


CHAPTER  III 
THE  ARTIFICIAL  INTERRUPTION  OF  PREGNANCY 

The  artificial  interruption  of  pregnancy  before  the  twenty- 
eighth  week  is  spoken  of  as  an  induced  abortion.  After  this 
time,  when  the  fetus  has  reached  a  viable  state,  the  interruption 
is  referred  to  as  an  induced  premature  birth. 

To  interrupt  pregnancy  before  the  twenty-eighth  week  means 
the  destruction  of  a  human  life,  and  should  not  be  undertaken 
lightly.  Furthermore,  it  is  a  punishable  offense,  except  it  be 
done  to  safeguard  the  mother's  life.  Nor  should  the  physician 
assume  the  responsibility  alone  of  performing  an  abortion.  For 
his  own  protection  it  is  wise  to  confer  with  some  one  else,  some 
one  whose  reputation  and  qualifications  as  an  obstetrician  are 
above  reproach.  Even  when  making  an  examination,  especially 
intrauterine,  the  possibility  of  the  patient  being  pregnant  must 
always  be  borne  in  mind. 

The  indications  for  voluntarily  interrupting  gestation  may  be 
described  under  two  general  heads:  (1)  those  conditions  due  to 
pregnancy  itself;  and  (2)  conditions  due  to  concurrent  affections. 

CONDITIONS  DUE  TO  PREGNANCY 

Hyperemesis  Gravidarum. — Vomiting  in  the  early  months  is 
so  constant  that  it  is  looked  upon  as  one  of  the  reliable  signs  of 
pregnancy.  Commonly  it  occurs  without  occasioning  much  in- 
disposition, so  that  no  special  consideration  need  be  given  to  it 
here.  The  cause  is  said  to  be  due  to  the  irritation  brought  about 
by  the  change  taking  place  in  the  uterus,  acting  on  the  stomach 
reflexly  through  the  vagus  nerve.  The  affliction  is  most  likely 
to  trouble  one  of  a  nervous  temperament,  becoming  clearly  a 
hysteroneurosis,  and  should  be  treated  as  such.  Rest  in  bed,  a 
modified  diet,  and  the  administration  of  bromides,  generally  re- 
lieve the  symptoms,  and  enable  the  patient  to  recover.    The  more 

49 


50 


THE    SURGICAL   PROCEDURES 


obstinate  eases  of  liyperemesis  gravidarum  ought  to  be  under 
hospital  supervision,  Avhere  care  and  treatment  can  be  more  ex- 
actly carried  out.  Simple  change  of  surroundings  supported  by 
suggestive  therapeutics,  is  sometimes  sufficient  to  effect  imme- 
diate cure. 


Fig.    S. — Murphy    proctoclysis    apparatus. 


ARTIFICIAL   INTERRUPTION    OF   PREGNANCY  51 

Treatment,  first  of  all,  should  aim  to  restore  nutritive  balance; 
and  it  is  especially  important  to  supply  water  to  the  system. 
This  is  accomplished  by  means  of  rectal  enemata.  An  excellent 
device  for  the  introduction  of  fluid  into  the  bowel  is  the  Murphy 
proctoclysis  apparatus  (Fig.  8).  With  it  water  can  be  introduced 
drop  by  drop,  as  much  as  a  liter  being  absorbed  in  the  course  of 
an  hour.  The  success  of  this  method  is  often  gratifying.  A  case 
in  illustration  is  cited: 

A  woman,  twenty-five  years  of  age,  began  vomiting  in  the  second  month  of 
her  second  pregnaucj',  at  first  in  the  morning,  then  after  each  meal,  and  con- 
tinued to  vomit  until  she  became  so  weak  that  she  had  to  remain  in  bed.  Med- 
ical treatment  failed  to  give  relief.  At  the  sixth  month  it  was  thought 
necessary  to  induce  abortion,  and  with  this  in  mind  she  was  taken  to  the 
hospital.  There,  instead  of  emptying  the  uterus,  she  was  kept  in  bed,  given 
rectal  alimentation,  hypodermoclysis,  and  proctoclysis.  She  improved  under 
this  treatment;  the  vomiting  ceased,  and  the  weight  increased.  At  the  end  of 
a  month  she  could  be  up  and  take  food  by  the  mouth. 

Unfortunately,  not  all  cases  of  hyperemesis  respond  thus  read- 
ily to  treatment.  Instead,  the  temperature  becomes  elevated,  the 
pulse  weak  and  rapid,  albumin  appears  in  the  urine,  the  urine 
itself  is  decreased  in  quantity,  and,  in  spite  of  hypodermoclysis 
and  proctoclysis,  the  affection  shows  no  abatement,  and  even  gets 
worse.  Such  a  state  is  undoubtedly  one  of  toxemia,  a  condition 
fatal  to  the  patient  unless  something  more  radical  be  done.  The 
liver  and  kidneys,  the  organs  most  vitally  concerned  in  the 
process  of  elimination,  have  already  been  taxed  beyond  their 
physiologic  limits ;  severe  and  long-lasting  emesis  has  interfered 
with  nutritive  assimilation;  and  the  fluids  have  been  abstracted 
from  the  body — all  of  which  leads  to  an  accumulation  of  toxic 
substances  in  the  blood,  which  helps  to  intensify  the  disease, 
and  which  ultimately  will  end  in  the  woman's  death  if  the  of- 
fending object,  the  ovum,  be  not  destroyed.  Neither  is  it  wise  to 
temporize  too  long,  for  sometimes  the  patient's  vitality  gets  so 
low  that,  even  after  the  uterus  has  been  emjDtied,  it  is  impossible 
for  her  to  rally  from  the  toxemia. 

The  Hydatidiform  Mole. — Cystic  degeneration  of  the  chorion, 
also  knoAvn  as  hydatidiform  mole,  progresses  rapidly  and  se- 
riously upon  the  blasting  of  the  fertilized  ovum.    Unconscious  at 


52 


THE   SURGICAL   PROCEDURES 


first  of  anything  unnsnal,  the  pregnant  woman's  attention  later 
is  called  to  a  peenliar  bloody  discharge.  Coincident  thereto  a 
destructive  process  is  going  on  in  the  uterine  Avail  which  may 
become  rapidly  fatal ;  and,  because  of  its  serious  nature,  such  a 
growth  must  be  removed  from  the  cavity  of  the  uterus  as  soon 
as  the  diagnosis  is  made.     (Figs.  9  and  10.) 


Fig.    9. — Hydatidiform    mole    filling    the    uterine    cavity.     (Kerr.) 


The  determining  characteristics  of  a  mole  are  its  rapid  develop- 
ment and  the  presence  of  villous  cysts  constantly  appearing  in 
the  discharges.  The  uterus  itself  is  more  nearlj^  spherical  in  form 
and  more  elastic  in  feeling  than  in  normal  pregnancy.  The  organ 
is  also  much  larger  than  would  be  expected  in  a  gestation  cor- 
responding to  the  time  of  pregnancy  claimed  by  the  patient.  No 
fetal  parts  can  be  felt;  and  no  fetal  movements  or  fetal  heart 


ARTIFICIAL   INTERRUPTION    OF   PREGNANCY 


53 


Fig.   10. — Hydatidiform   mole.      (Kerr.) 


54  THE    SURGICAL   PROCEDURES 

sounds  are  to  be  made  out.     There  is  general  anemia  and  weak- 
ness. 

The  following  case  came  under  my  care  at  the  University 
Hospital: 

Mrs.  W.,  thirty-three  years  of  age,  a  decipara,  Austrian.  Always  well  and 
strong,  with  the  exception  of  an  occasional  disturbance  of  the  stomach.  Pre- 
vious pregnancies  normal. 

March  1.  Patient  began  to  liaA'e  severe  pain  in  lower  abdomen,  and  to  flow 
profusely.  Thought  she  was  pregnant  because  the  womb  was  enlarging.  Flow 
continued,  and  on  March  27  she  came  to  the  hospital  with  a  diagnosis  of  in- 
complete abortion  at  two  and  one-half  months. 

Very  weak  and  pale.  The  fundus  of  the  uterus  extended  to  the  umbilicus; 
mass,  boggy  and  irregular;  no  fetal  parts  made  out. 

On  March  29,  patient  suffered  a  sudden  gush  of  fluid,  mostly  water,  but 
tinged  with  blood.    A  clinical  diagnosis  of  hydatidiform  mole  was  made. 

On  April  1,  five  days  after  admission,  the  cervix  was  dilated  with  a  Leavitt 
dilator,  and  the  uterine  contents  carefully  removed  with  a  large  dull  curette. 
Quantities  of  cysts  were  brought  away. 

For  several  days  there  followed  a  bloody  discharge,  which  later  became 
offensive  and  purulent. 

Examined  the  eleventh  day,  the  fundus  could  be  felt  above  the  pubes,  firm 
but  tender  to  the  touch.  That  night  the  patient  complained  of  pain  in  the 
region  of  the  bladder,  and  on  the  day  following  she  began  to  flow,  clots  and 
bright  blood,  which  continued  with  intermissions  for  several  days. 

April  3.  The  uterus  found  above  the  symphysis;  rather  boggy;  sensitive. 
In  size,  the  mass  was  about  as  large  as  the  fist.  Seen  in  consultation  with 
another  member  of  the  staff,  she  was  transferred  from  the  obstetric  to  the  sur- 
gical ward  of  the  hospital. 

April  26.  Operation.  Uterus  enlarged;  ovaries  and  tubes  matted  together. 
Uterus,  tubes,  and  ovaries  removed ;  also  a  small  growth  excised  from  the  upper 
margin  of  the  vaginal  orifice. 

Pathologic  findings:  Uterus  8  cm.  in  length;  walls  2  to  3  cm.  thick.  No 
ulcerations  apparent.     Tubes  8  cm.  long,  and  normal.    Ovaries  large  and  cystic. 

Microscopic  examination  of  the  cysts,  removed  soon  after  admission  to  the 
hospital,  showed  large  villi  covered  with  chorionic  epithelium,  and  containing  a 
few  spindle-shaped  cells  with  interstitial  substance  resembling  mucin.  Sections 
of  the  uterus  showed  groups  of  syncytial  masses,  much  more  numerous  in  some 
sections  than  in  others.  Slight  necrosis  around  some  of  the  large  superficial 
groups.  The  tissues  excised  from  the  A'aginal  orifice  proved  to  be  benign, 
though  several  small  syncytial  masses  similar  to  the  ones  in  the  uterus  were 
found  in  portions  of  the  upper  wall. 

Diagnosis:  (1)  hydatidiform  mole;  (2)  syncytial  mass  suggestive  of  malig- 
nancy;   (3)   metastasis  in  vaginal  wall. 

Subsequent  condition :  Seen  six  months  after  the  operation,  no  indications 
of  malignancy  were  to  be  found. 


ARTIFICIAL    INTERRUPTION    OF   PREGNANCY  55 

Acute  Hydramnion. — There  are  two  conditions  which  may  be 
the  cause  of  acute  hydramnion, — fetal  malformation  and  mul- 
tiple gestation.  Either  of  these  may  occasion  a  great  increase  in 
the  amount  of  amniotic  fluid,  so  much  so  that  even  in  the  early 
months  the  abdomen  Avill  have  the  appearance  of  a  full-time 
pregnancy.  Such  rapid  distention  is  accompanied  by  pain  and 
dyspnea  and  may,  under  certain  circumstances,  have  associated 
with  it  a  cardiac  insufficiency. 

Treatment  calls  for  the  interruption  of  pregnancy,  to  which 
one  agrees  readily,  since  at  best  in  this  disease  the  child  is  lost. 

Retention  of  a  Dead  Ovum. — Sometimes  the  fruit  of  concep- 
tion dies,  but  does  not  at  once  come  aw^ay.  In  rare  instances  the 
dead  embryo  remains  for  weeks  within  the  uterus  without  no- 
ticeably influencing  the  maternal  organism,  but,  should  there  be 
evidence  of  fetal  death,  the  uterus  ought  to  be  emptied. 

Habitual  Death  of  the  Child. — Now  and  again  it  happens,  and 
without  explanation,  that  the  child  dies  short  of  term.  Fre- 
quently, as  is  well  known,  its  death  can  be  accounted  for  through 
lues;  but  in  a  surprisingly  large  number  of  cases  the  etiology  re- 
mains unknow^n.  Now,  if  one  be  astute  enough  to  anticipate  this 
unfortunate  behavior  by  inducing  labor  while  the  child  is  still 
viable,  he  perhaps  may  prevent  its  death;  but  no  one  lays  claim 
to  such  powers  of  discernment.  One  can  only  act  on  the  theory 
that,  inasmuch  as  death  under  similar  circumstances  had  oc- 
curred several  times  before,  it  might  be  prevented  by  bringing 
on  labor  prematurely. 

Displacements  of  the  Gravid  Uterus. —  (a)  Retroversion.  (Fig. 
11.)  When  the  retroflexed  uterus  becomes  pregnant,  the  rule  is 
that  it  will  right  itself  at  about  the  third  month  and  remain  in 
the  abdominal  cavity.  Occasionally,  hoAvever,  it  does  not  behave 
thus  favorably;  it  persists  as  a  pelvic  organ,  where  it  continues 
to  undergo  further  growth  and  development.  Under  such  cir- 
cumstances symptoms  of  pressure  folloAv  in  the  fourth  and  fifth 
months.  The  enlarging  uterus  shuts  off!  the  urethral  canal,  caus- 
ing overdistention  of  the  bladder.  The  rectum  also  suffers,  but 
not  to  the  same  degree.  If  this  state  of  things  continues,  gan- 
grene of  the  bladder  Avith  fatal  peritonitis  Avill  ultimately  fol- 
low.    Most  women,  however,  Avill  consult  their  physician  early 


56 


THE   SURGICAL   PROCEDURES 


BlacUer 


Uve^lWrs 


Toftio 
Vagirvz>A»5 


Vft<ji>\a 


Fig.    11. — Retroverted    gravid   uterus.      (Runge.) 


enoiigh  to  have  the  imprisoned  organ  released  while  release  is 
still  possible. 

The  following  are  the  typical  findings  in  incarceration  of  the 
gravid  uterus,     Above  the  symphysis  is  found  a  cystic  tumor 


ARTIFICIAL   INTERRUPTION    OF   PREGNANCY 


57 


oxteiiding  upward  to  the  navel, — the  distended  bladder.  Within 
the  vagina,  which  is  much  reduced  in  size,  the  cervix  lies  shelv- 
ing across  the  anterior  vault;  behind,  the  posterior  vault  of  the 
vagina  and  the  cul-de-sac  of  Douglas  are  filled  with  an  elastic 
tumor, — the  body  of  the  uterus. 

The  first  step  to  be  taken  in  attempting  to  reduce  such  a  dis- 
location, is  to  empty  the  bladder  cautiously  by  catheterization. 


Fig.    12. — Manual    reduction    of    the    retrodisplaced    gravid    uterus.       (Bunim.) 


This  procedure  alone  may  sometimes  be  sufficient.  Next,  the 
patient  should  be  anesthetized,  the  entire  hand  passed  into  the 
vagina,  and  if  possible  the  body  of  the  uterus  elevated.  This 
maneuver  having  failed  Avith  the  patient  lying  on  her  back,  she 
is  then  placed  in  the  knee-chest  position,  and  an  effort  is 
made  to  push  the  uterus  beyond  the  promontory  of  the  sacrum. 
(Fig.  12.)     The  colpeurynter,  placed  in  the  vagina  and  gradually 


58  THE    SURGICAL   PROCEDURES 

distended  with  water,  is  an  excellent  expedient  in  lieu  of  the  hand. 
Such  maneuvers  mar  be  continued  for  a  considerable  length  of 
time,  care  being  taken  frequently  to  empty  the  bladder. 

There  are  two  conditions  which  maj^  arise  to  make  reposition 
impossible:  First,  the  body  of  the  uterus  may  be  immobilized 
by  inflammatory  adhesions;  and,  second,  the  pelvic  inlet  may  be 
so  contracted  that  the  enlarged  uterus  can  not  be  forced  through 
it  into  the  false  pelvis  above.  In  the  former  situation  the  uterus 
may  be  freed  through  abdominal  operative  procedure;  but,  most 
likely,  this  would  interrupt  pregnancy,  and  Avould,  of  course,  fail 
if  the  inlet  were  contracted. 

(b)  Prolapse  of  the  Uterus. — ^Women  with  persistent  total 
prolapse  of  the  uterus  seldom  become  pregnant.  "When  concep- 
tion takes  place  under  this  condition,  the  uterus  draws  itself 
back  into  the  pelvis  as  enlargement  goes  on.  Unless  it  becomes 
reduced  in  this  way,  spontaneous  abortion  must  result.  So, 
whenever  it  is  found  impossible  manually  to  replace  the  gravid 
uterus,  pregnancy  should  be  interrupted. 

Spatial  Inadequacy. — In  cases  which  present  a  disproportion 
between  the  head  of  the  child  and  the  pelvis  of  the  mother,  es- 
pecially if  such  inadequacy  has  been  observed  in  a  former  preg- 
nancy, it  is  well  to  consider  the  advantages  of  premature  labor; 
for  with  a  smaller  and  more  plastic  head  there  are  fewer  me- 
chanical difficulties  to  overcome  than  at  full  term.  Troublesome 
disproportions  seldom  occur  in  the  woman  of  normal  develop- 
ment ;  but  in  such  as  have  a  contracted  pelvis,  premature  induc- 
tion of  labor  is  one  of  the  procedures  to  be  thought  of.  The 
various  methods  of  inducing  labor  will  be  dealt  with  later. 

In  passing  it  may  be  remarked  that  when  a  woman  with  a 
contracted  pelvis  comes  under  obserA-ation,  one  is  often  puzzled 
as  to  hoAv  to  proceed, — to  apply  forceps,  induce  labor  at  the 
eighth  month,  perform  version,  separate  the  pubes,  or  do  an 
abdominal  section.  The  specific  advantages  of  each  procedure 
will  be  discussed  under  its  appropriate  head.  Our  object  is  to 
get  the  child  past  the  obstruction;  and,  obviously,  the  smaller 
the  object  the  easier  it  will  pass.  For  this  reason  labor,  if 
induced  at  all,  should  be  induced  at  the  earliest  possible  time 
consistent  with  safety  to  the  child. 


ARTIFICIAL   INTERRUPTION    OF   PREGNANCY  59 

Theoretically,  a  child  is  viable  after  the  twenty-eighth  week. 
Instances  of  its  surviving  when  born  at  this  age  are  on  record; 
but,  practically,  one  can  not  reckon  on  a  child  living  that  is  un- 
der thirty-four  weeks.  Even  this  early  its  head  will  be  too  large 
to  pass  through  the  pelvis  if  the  true  conjugate  is  less  than  8  cm. 
in  diameter.  On  the  other  hand,  the  longer  a  child  remains  in  the 
uterus,  and  the  more  developed  it  becomes,  the  larger  and 
harder  its  head  grows  to  be.  So  that,  in  considering  the  advis- 
ability of  inducing  labor  prematurely,  three  things  should  be 
borne  in  mind:  (1)  the  stage  of  pregnancy;  (2)  the  degree  of 
pelvic  contraction;  and  (3)  the  size  of  the  child's  head. 

The  duration  of  pregnancy  is  generally  reckoned  from  the  be- 
ginning of  the  last  menstrual  period;  but,  under  certain  circum- 
stances, it  may  be  calculated  more  exactly.  It  may  also  be  esti- 
mated by  making  measurements  of  the  child  in  uiero,  noting  its 
movements,  listening  to  its  heart,  and  palpating  its  body.  In 
not  overthick  abdominal  walls  it  is  possible  to  measure  the  fetus 
with  the  pelvimeter.  The  head  is  sometimes  so  easily  palpated 
that  its  size  can  be  determined  after  the  method  of  Mueller,  that 
is,  by  forcing  the  head  into  the  superior  strait  by  means  of  pres- 
sure made  with  the  hands  from  above.  The  examination  should 
determine  whether  the  fetus  is  alive  and,  also  whether  there  is 
more  than  one  child. 

In  first  pregnancies  induction  of  premature  birth  is  to  be 
thought  of  only  in  exceptional  cases,  for  the  reason  that  a  test 
of  labor  has  never  been  made.  Owing  to  the  small  size  and 
moldability  of  a  child's  head,  a  great  number  of  deliveries  in 
contracted  pelves  are  spontaneous;  and  experience  has  taught 
us  that  in  most  instances  nature  is  surprisingly  competent.  We 
shall  have  to  admit  that  as  yet  we  have  not  acquired  that  exact 
knowledge  which  enables  us  to  say  just  when  is  the  proper  time 
to  induce  labor. 

Having  considered  the  l^asic  principles  underlying  the  pro- 
cedure of  inducting  labor  prematurely,  it  is  well  to  revicAV  the 
results,  and  take  a  look  at  statistics.  In  2,200  reported  cases, 
two  mothers  and  fifty-six  babies  in  every  one  hundred  and  fifty 
deliveries  died  (1.3  per  cent  mortality  for  the  mother  and  37 
per  cent  for  the  child) .    This  is  not  a  very  good  showing  for  the 


60  THE    SURGICAL   PROCEDURES 

child,  not  nearly  so  good  as  in  cesarean  section  or  pubiotomy; 
but  for  the  mother  the  mortality  is  lower  than  in  either  of  these 
operations.  For  her  the  procedure  is  practically  harmless.  Of 
938  women  with  contracted  pelves  who  went  their  full  time, 
only  34.5  per  cent  of  the  children  lived,  while  the  same  women, 
prematurely  delivered,  gave  birth  to  71.9  per  cent  of  living  chil- 
dren,— a  fetal  mortality  of  65.5  per  cent  and  28.1  per  cent, 
respectively. 

The  induction  of  premature  birth,  therefore,  may,  in  condi- 
tions of  pelvic  inadequacy,  be  considered  a  prophylactic  opera- 
tion. The  excellent  results  obtained  warrant  its  undertaking. 
The  following  clinical  history  illustrates  its  advantage  in  the 
case  of  a  woman  who  experienced  four  pregnancies: 

Pelvic  measurements :  intcrsi^inous,  2.3.4  cm. ;  interciistal,  26.5  cm. ;  external 
conjugate,  18.8  cm.;  diagonal  conjugate,  10.3  cm.;  true  conjugate,  8.5  cm., 
a  generally  contracted  flat  pelvis. 

The  first  pregnancy  went  to  term.  The  child  's  liead  had  to  be  j)erf  orated. 
The  second  terminated  in  a  spontaneous  abortion. 

Version  was  performed  in  the  third.  The  child  died  during  the  delivery  of 
the  after-coming  head. 

At  the  37th  week  of  the  fourth  pregnancy,  labor  was  prematurely  brought 
on.     The  child  lived;  weight,  2890  grams. 

CONDITIONS  DUE   TO   CONCURRENT  AFFECTIONS 

Org-anic  Heart  Disease. — A  diseased  heart  will,  through  degen- 
erative changes,  be  greatly  influenced  by  pregnancy  and  labor. 
The  increased  vascularization  causes  it  to  become  burdened  with 
extra  work.  It  also  comes  al^out,  especially  in  the  later  months 
of  pregnancy,  that  the  growth  of  the  uterus  increases  the  intra- 
abdominal pressure,  and  thereby  tends  to  impede  the  reflux  of 
blood  from  the  loAver  half  of  the  body,  which  in  the  tortuous  and 
distended  veins  can  be  overcome  only  by  greater  efforts  on  the 
part  of  the  heart.  A  further  injurious  effect  lies  in  the  waste 
products  of  the  embryo  l)eing  taken  up  hy  the  maternal  circula- 
tion, the  so-called  toxines  of  pregnancy;  and,  depending  on 
their  quantity  and  toxicity,  they  acquire  an  influence  on  the 
heart.    And,  finally,  pregnancy  has  a  marked  psychic  effect  on  the 


ARTIFICIAL   INTERRUPTION   OF   PREGNANCY  61 

heart,  particulai'ly  when  accompaniefl  hy  an  apprehensive  state 
of  mind. 

At  tlie  time  of  ]al)or  still  greater  demands  are  pnt  on  the 
activity  of  the  heart.  Dnring  each  pain,  especially  in  the  ex- 
pulsive stage,  the  pressure  in  the  vascular  system  is  acutely  and 
sometimes  dangerously  increased;  the  frequency  of  the  pulse 
begins  to  rise  at  the  onset  of  a  contraction,  and  subsides  slowly 
with  the  passing  of  the  pain.  At  the  moment  the  child  is  born, 
a  significant  fluctuation  takes  place  in  the  vascular  pressure. 
The  intraabdominal  pressure  sinks,  and  coincidently  a  strong 
influx  of  blood  occurs  in  the  vessels  of  the  belly  cavity. 

During  the  puerperium  all  these  phenomena  slowly  return  to 
normal,  but  the  influence  on  the  cardia  lasts  for  some  time 
because  of  the  arterial  tension.  After  delivery,  large  vascular 
areas  are  formed  in  the  circulation,  which,  together  with  the 
absorption  of  fat  and  other  products  of  involution,  have  the 
effect   of   continuing  the    circulatory   disturbances    still   longer. 

How  does  nature  take  care  of  these  changes?  Not  only  the 
sound  organ  withstands  the  increasing  demands,  but  even  a  heart 
with  valvular  insufficiency  is  not  affected,  or,  at  least,  very  little, 
if  compensation  remains  undisturbed.  A  surprisingly  large 
number  of  women  with  heart  disease  go  through  childbirth  with- 
out presenting  any  ill  symptoms  whatsoever.  But  heart  disease 
may  have  an  altogether  different  meaning  if  compensatory  dis- 
turbances manifest  themselves.  On  the  one  hand,  the  insuffi- 
ciency may  be  incidental  with  the  pregnancy  itself;  on  the  other 
it  may  be  due  to  the  contingent  demands  made  on  the  heart  at 
the  time.  Under  such  circumstances  the  lesion  can  become  se- 
rious enough  to  cause  death,  even  during  pregnancy,  unless 
therapeutic  measures  are  promptly  applied.  Let  me  cite  a  case 
in  illustration: 

At  the  age  of  seven,  a  girl  suffered  an  attack  of  scarlet  fever  and  diphtheria 
with  an  acconijaanying  nephritis.  She  never  fully  recovered,  complaining  in 
particular  of  palpitation  of  the  heart  and  shortness  of  breath.  Under  medical 
treatment  she  got  so  she  could  do  light  work,  and  had  no  compensatory  dis- 
turbance of  the  heart.  At  twenty-three  she  became  pregnant.  Early  in  the 
first  month  her  difficulties  began  to  increase,  especially  the  palpitation  and 
edema,  so  that  she  was  forced  to  remain  in  bed  most  of  the  time.     From  the 


62  THE    SURGICAL   PROCEDURES 

fiftli  month  on  the  dyspnea  became  increasingly  worse,  growing  so  severe  that 
she  was  obliged  to  go  to  the  hospital. 

Upon  admission,  the  findings  were  as  follows:  fetus  of  medium  size;  edema 
of  both  legs  extending  to  the  thighs;  swelling  of  the  abdominal  skin  and  face; 
marked  cyanosis.  Cold  e:!itremities ;  anxious  countenance;  orthopnea.  Tem- 
perature slightly  subnormal.  The  apex  beat  was  at  about  the  sixth  interspace, 
to  the  left  of  the  mammillary  line.  A  loud  bruit  could  be  heard  over  the  sternum 
and  apex.  Heart  action,  regular,  100  to  108.  Very  small  pulse;'  poor  quality; 
hard  to  count;  changeable.  Attacks  of  suffocation.  The  fundus  of  the  uterus 
reached  a  handbreadth  above  the  umbilicus;  the  head  and  small  parts  were 
not  palpable.    Fetal  heart  sounds  and  fetal  movement,  not  demonstrable. 

First  of  all,  the  gravity  of  the  compensatory  disturbance  was  combated 
through  stimulation.  Digitalin  was  given  hj-podermically,  followed  by  half- 
hourly  doses  of  camphorated  oil  and  hot  applications  over  the  heart.  This 
gave  little  relief,  though  for  the  time  being  the  pulse  was  perceptibly  better. 
After  one  hour,  the  conditions  grew  rapidly  worse ;  the  sensorium,  hitherto 
clear,  became  cloudy,  and  death  ensued. 

The  autopsy  showed  chronic  endocarditis;  mitral,  tricuspid,  and  aortic  ste- 
nosis; hypertrophy  and  dilatation  of  the  heart  chambers;  fatty  degeneration; 
hydrothorax  and  pericardial  effusion ;  and  general  anasarca. 

Compensatory  disturbances  during  pregnancy  are  treated  as 
they  would  be  at  other  times.  In  order  that  physical  and  mental 
excitement  may  be  reduced  as  much  as  possible,  the  patient 
should  be  kept  in  bed,  the  diet  carefully  regulated,  and  proper 
heart  tonics  given.  Digitalis  and  strophanthus  are  the  two 
drugs  most  frequently  employed.  If,  after  following  this  treat- 
ment for  a  week  or  ten  days,  the  disease  is  not  better,  pregnancy 
will  have  to  be  interrupted. 

It  frequently  happens  that  in  one  pregnancy  there  is  no  dis- 
turbance of  the  heart,  or  very  little,  while  in  another  pregnancy 
the  same  woman  will  develop  such  alarming  symptoms  that 
one  is  called  upon  to  advise  against  a  repetition  of  the  risk. 
And,  if  the  lesion  is  so  serious  that  gestation  must  be  interrupted 
in  order  to  save  the  patient's  life,  it  should  be  borne  in  mind  that, 
even  though  she  reach  term,  there  is  a  further  danger  from  the 
process  of  birth  itself. 

The  following  case  illustrates  well  how  differently  heart  dis- 
ease may  be  affected  by  one  pregnancy  as  compared  with  an- 
other in  the  same  individual: 

Patient  thirty-eight  years  of  age.  Had  an  attack  of  chorea  in  childhood. 
In  her  twenty-sixth  year  she  noticed  for  the  first  time  that  in  performing  her 


ARTIFICIAL   INTERRUPTION    OF    PREGNANCY  63 

household  duties  she  became  easily  tired,  and  experienced  difficulty  in  breath- 
ing. A  physician  was  consulted,  who  found  a  severe  heart  lesion.  In  the 
twelve  years  following  she  was  pregnant  eight  times. 

First  pregnancy:  No  difficulties  experienced  during  the  whole  period. 
Labor  lasted  twenty-four  hours,   and  was  quite  normal. 

Second  pregnancy,  four  years  later:  At  about  the  sixth  month  the  heart 
began  to  give  trouble,  and,  as  she  grew  worse,  she  was  taken  to  the  hospital 
near  the  end  of  gestation.  Examination  sliowed  mitral  insufficiency  with  severe 
compensatory  disturbance,  complicated  by  double  hydrothorax,  nephritis,  an- 
asarca, and  edema  of  the  labia.  In  spite  of  treatment,  induction  of  premature 
labor  became  necessary.  Compensation  rapidly  returned.  Because  of  the 
severe  type  of  the  disease,  the  patient  was  strongly  advised  not  to  permit  an- 
other conception — she  was  even  urged  to  undergo  an  operation  for  steriliza- 
tion. All  admonitions  were  disregarded,  and  within  a  few  months  she  again 
became  pregnant. 

Third  pregnancy:  This  ran  without  disturbance  until  the  fourth  month, 
when  a  spontaneous  abortion  terminated  gestation. 

Fourth  pregnancy:  Gestation  progressed  well  until  the  last  month,  when 
she  began  to  suffer  from  palpitation  and  shortness  of  breath.  She  had  a  spon- 
taneous labor  at  term  and  passed  a  normal  puerperium. 

Fifth  pregnancy :  Up  to  the  fourth  month  without  trouble ;  then  followed 
palpitation  and  shortness  of  breath,  also  swelling  of  the  feet.  Tliese  symp- 
toms continued  to  grow  worse  until  the  seventh  month,  when  miscarriage  took 
place. 

Sixth  pregnancy:  TIic  first  f\\Q  months  were  without  interest.  There  was 
then  a  return  of  the  palpitation,  vertigo,  and  shortness  of  breath.  In  the 
eighth  month  premature  liirth  relieved  tlie  symptoms. 

Seventh  pregnancy:  Tlierc  was  no  cardiac  disturbance,  but  the  patient 
aborted  in  the  fifth  month. 

Eighth  pregnancy:  This  time  the  j)atient  went  six  months  without  com- 
plications. In  the  seventh  she  had  a  return  of  the  symptoms  noted  in  the 
former  pregnancies.  Without  other  involvement  than  that  of  the  heart,  she 
gave  birth  to  a  dead  fetus. 

The  severe  and  complex!  heart  symptoms  arising  in  the  second  pregnancy 
were  made  worse  by  nephritis.  In  most  of  the  other  gestations,  spontaneous 
interruption  occurred  before  any  marked  damage  was  done  the  heart  and  before 
the  kidneys  were  affected.  Only  twice  out  of  eight  times  was  a  fully  developed 
child  born. 

Pulmonary  and  Laryngeal  Tuberculosis. — The  influence  of 
pregnancy  on  a  patient  with  pulmonary  tuberculosis  is  peculiar 
and  varied.  The  disease,  which  till  then  remained  latent,  now 
makes  its  first  appearance,  or  may  take  on  increased  momentum 
if  already  manifest.  In  any  case,  the  concurrence  of  pregnancy 
and  tuberculosis  is  a  serious  matter.     Cases  in  Avhich  beginning 


64  THE    SURGICAL   PROCEDURES 

or  latent  tuberculosis  exists  ^vithout  effecting  any  noticeable 
changes  during  gestation,  later  show  more  or  less  damage  from 
the  complication  through  which  the  patient  has  passed.  This 
is  accounted  for  by  the  fact  that  respiratory  movement  becomes 
limited,  and  in  consequence  the  lung  tissue  receives  less  aeration, 
circulation  is  interfered  with,  and,  eventually,  nutritive  disturb- 
ances become  manifest.  In  this  way  tuberculosis  of  the  lungs 
may  make  insidious  headway  during  pregnancy.  When  labor 
comes  along,  the  blood  pressure,  especially  at  the  height  of  a 
pain,  rises,  and  this,  added  to  the  increased  demands  made  on  the 
lungs,  acts  unfavorably  on  the  disease. 

The  accepted  facts  concerning  tuberculosis  make  it  a  positive 
duty  to  watch  very  closely  every  case  of  concurrent  pregnancy 
and  phthisis.  As  the  physiologic  symptoms  increase,  the  body 
weight  decreases,  the  temperature  rises,  the  pulse  is  quickened, 
end.  possibly,  hemorrhage  or  a  pleuritis  may  occur.  In  deter- 
mining the  diagnosis  one  may  make  use  of  the  ophthalmic  or  some 
other  reaction.  A  negative  result  is  favorable,  inasmuch  as  it 
proves  the  existence  in  the  bod}*  of  immunizing  substances.  A 
positive  reaction,  on  the  other  hand,  is  unfai^orable,  and  is  to  be 
considered  in  connection  with  the  contemiDlated  interference. 
The  following  is  a  case  in  mind: 

A  tuberculous  multifiara,  tliiitT-one  years  of  age. 

About  a  year  before  the  seventli  coueeption,  sticking  pains  began  in  the 
chest,  accompanied  by  a  profuse  expectoration.  These  symptoms  became  ag- 
grayated  during  pregnane}'  and  emaciation  was  rapid.  In  the  third  month 
adventitious  sounds  could  be  lieard  over  both  apices,  and  tubercle  bacilli  were 
found  in  the  sputum.  An  abortion  was  performed,  followed  by  quick  recovery. 
Three  years  later  another  pregnancy,  with  fewer  lung  symptoms  followed.  A 
spontaneous  abortion  occurred  in  the  third  month.  After  some  years  more, 
she  conceived  again.  This  time  the  lung  symptoms  were  much  aggravated ;  pro- 
fuse expectoration ;  fever ;  and  pleuritis.  Eef using  all  therapeutic  measures, 
spontaneous  abortion  took  place  between  the  second  and  third  months,  after 
which  slie  improved  rapidly. 

The  indications  for  interference  do  not  apply  if  the  tuberculosis 
has  reached  such  a  hopeless  state  that  only  the  preservation  of 
the  child  is  to  be  considered.  To  illustrate:  A  patient  in  the 
seventh  month  of  gestation,  suffering  from  severe  lung  and 
larynx  tuberculosis,   consults  the   obstetrician,   who   finds  upon 


ARTIFICIAL    INTERRUPTION    OF    PREGNANCY  65 

examination  that  the  disease  is  far  advanced.  Shall  he  advise 
the  induction  of  premature  labor?  In  the  interest  of  the  child, 
no ;  as  for  the  woman  herself,  nothing  will  be  gained.  If  the 
indications  for  concluding  gestation  assert  themselves  near  the 
end  of  pregnancy,  it  may  be  possible  to  defer  interference  to  a 
time  when  the  child's  chances  of  living  are  most  favorable — 
when  one  has  only  the  effect  of  the  birth  itself  to  consider. 

As  a  preparatory  measure,  in  case  pregnancy  should  occur 
again,  it  is  recommended  that  forced  feeding  be  begun  soon. 
Sterilization  may  properly  be  advised  in  some  instances. 

Tuberculosis  of  the  larynx  is  a  particularly  severe  and  incur- 
able form  of  the  disease.  Indeed,  the  outlook  is  so  bad  that  once 
the  diagnosis  is  made,  pregnancy  must  invariably  be  interrupted. 

Nephritis. — As  excretory  organs  the  kidneys  hold  a  high  place, 
especially  during  pregnancy.  It  is  largely  through  them  that 
must  take  place  the  elimination  of  waste  products  which  find 
their  way  into  the  blood,  elements  which  carry  with  them  irri- 
tation and  injury  to  the  kidneys.  These  irritating  substances  show 
their  effect  by  causing  albumin  to  appear  in  the  urine ;  the  secre- 
tion is  also  diminished,  and  the  lower  extremities  become  swol- 
len. A  nephritis  can  exist  during  gestation  without  essential 
organic  change,  and  afterward  the  patient  become  entirely 
Vv'ell;  and  for  this  reason  it  is  usually  unnecessary  to  apply 
therapeutic  measures  for  its  relief,  more  than  to  keep  in  check 
the  injurious  effects  by  appropriate  regulation  of  the  diet.  In 
other  cases  the  picture  becomes  more  serious.  There  may  be 
continuous  headache,  vomiting,  loss  of  appetite,  malnutrition, 
and  dropsical  effusions  in  the  serous  cavities,  which  are  symptoms 
that  demand  more  active  treatment.  The  patient  should  be  put 
to  bed,  and  allowed  only  a  milk  diet.  If  these  measures  fail  to 
bring  about  an  improvement,  the  interruption  of  pregnancy  is 
demanded.  With  its  termination  all  indications  of  nephritic 
insufficiency  disappear. 

In  contrast  with  this  aspect  of  the  affection,  it  occasionally 
happens  that  the  kidneys  will  exert,  through  the  influences  of 
the  irritating  substances  which  their  disordered  condition  brings 
about,  a  damaging  influence  on  the  cerebrum,  especially  disturb- 
ances of  vision.    These  may  sometimes  be  purely  functional  with 


66  THE    SURGICAL    PROCEDURES 

no  positive  alteration  in  the  eye-grounds;  but  in  other  instances, 
mostly  of  slow  development,  there  occurs  a  perceptible  affection 
of  the  fundus,  such  as  albuminuric  retinitis,  hemorrhage,  or  sepa- 
ration of  the  retinal  membrane.  Such  lesions  carry  Avith  them  a 
considerable  percentage  of  persistent  changes  in  the  eye,  even 
blindness.  For  this  reason,  interruption  of  pregnancy  is  indi- 
cated upon  their  first  appearance.  And,  surely,  one  would  make 
a  grave  mistake  not  to  knoAv  of  the  existence  of  a  perma- 
nent chronic  nephritis  in  his  patient.  All  the  injuries  that  have 
been  mentioned  can  then  happen  from  the  beginning  of  preg- 
nancy, developing  most  alarming  symptoms  of  uremia  and  ter- 
minating in  death. 

Furthermore,  an  exacerbation  of  a  quiescent  kidney  lesion  can 
folloAv  upon  the  termination  of  pregnancy;  and  this  is  another 
reason  Avhy  a  Avoman  Avith  a  chronic  nephritis  should  have  gesta- 
tion interrupted. 

An  acute  nephritis  appearing  in  pregnancy  seldom  demands 
interference.  Either  the  nephritis  runs  on  Avith  the  pregnancy 
or  the  pregnancy  ends  spontaneously,  as  it  does  in  many  of  the 
infectious  fevers. 

Pyelitis. — Coming  on  in  pregnancy,  pyelitis  like  nephritis,  is 
seldom  an  indication  for  inducing  labor.  In  the  majority  of  cases 
the  pyelitis  runs  its  course  Avithout  particularly  endangering 
the  pregnancy,  proAdded,  of  course,  that  the  inflammation  is 
properly  treated  by  rest  in  bed,  Avith  a  milk  diet,  an  ice  bag  over 
the  renal  region,  and  urotropin.  Only  in  the  rarest  cases  of  this 
kind  is  one  compelled  to  interfere  Avith  pregnancy,  and  then 
only  Avhen  the  symptoms  are  of  such  severity  that  one  has  to 
reckon  AAdth  death. 

Chorea. — Those  Avho  suffered  from  the  disease  in  childhood 
are  said  to  be  more  liable  than  others  to  have  it  during  ges- 
tation. It  may  come  on  slowly  and  run  a  mild  course;  or  it  may 
begin  acutely  and  become  dangerous.  The  poisons  in  the  severer 
forms  of  the  affection  excite  such  violent  muscular  actiAdty  that 
the  patient  groAvs  exhausted ;  and,  in  complication  Avith  other 
closely  associated  diseases,  such  as  endocarditis  and  erysipelas, 
death  may  foUoAv.  As  many  as  forty-five  deaths  in  tAvo  hundred 
and  fifty-fiA^e  cases  have  been  reported.     Inasmuch  as  the  chorea 


ARTIFICIAL    INTERRUPTION    OF    PREGNANCY  67 

ends,  as  a  rule,  with  the  expiration  of  pregnane}",  a  severe  attack 
may  demand  that  gestation  he  interrupted. 

Diabetes  Mellitus. — ^Diabetes  in  pregnancy  can  give  rise  to  se- 
rious complications.  Judging  from  the  relative  frequency  of  the 
disease,  there  seems  to  he  a  certain  connection  between  liver  func- 
tion and  the  waste  products  of  gestation.  Under  some  circum- 
stances the  diabetes  remains  stationary.  Upon  a  proper  diet,  to- 
gether with  a  suitable  physical  and  mental  regimen,  the  preg- 
nancy goes  on  to  a  favorable  termination  and  without  specially 
aggravating  the  diabetes.  In  other  cases  the  concurrent  disease 
has  a  tendency  to  grow  worse.  To  interrupt  pregnancy  may  save 
life  in  bad  cases,  if  clone  soon  enough.  The  operation,  therefore, 
must  not  be  long  delayed  if  sugar  persists  and  acetone  appears 
in  the  urine. 

Blood  Disease. — The  etiology  of  pernicious  anemia  is  obscure. 
The  symptoms  are  a  waxlike  pallor,  apathy,  dyspnea,  hemic  heart 
murmurs,  great  weakness,  and  insufficient  nutrition.  Examina- 
tion of  the  blood  shows  a  remarkable  diminution  of  both  red 
cells  and  hemoglobin.  Megaloblasts,  poikilocytes,  and  microeytes 
appear.  The  affection  almost  always  has  a  fatal  termination,  which 
pregnancy  helps  to  hasten.  Likewise  leukemia  with  its  striking 
augmentation  of  white  cells  and  its  diminished  number  of  red 
cells,  together  with  the  formation  of  a  splenic  tumor  and  en- 
larged lymph  glands,  will,  in  rare  cases,  constitute  a  complication 
ending  in  death.  Hemophilia  is  manifested  at  the  time  of  delivery, 
especially  in  the  third  stage,  the  danger  being  from  hemorrhage. 

METHODS  OF  INDUCING  ABORTION 

The  technic  of  artificially  emptying  the  uterus  depends  for  its 
ease  of  accomplishment  upon  the  time  of  pregnancy,  the  size  of  the 
embryo  determining  the  manner  of  performing  the  operation. 
Within  the  first  four  or  five  months  it  is  necessary  either  to  dilate 
the  cervical  canal  and  excite  the  uterus  to  expel  its  contents,  or, 
after  dilating,  to  enter  the  cavity  and  remove  the  ovum.  There 
are  several  waj^s  of  doing  this. 

The  Tampon.— The  patient  is  placed  on  the  bed  crosswise,  and, 
after  the  necessary   cleansing   and   sterilization,   the  vagina   is 


THE    SURGICAL   PROCEDURES 


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o 


jii 


(I- 


A  B.  C".  . 

Fig.   13.— Laminaria  tents.     A   and  B  represent  two  sizes:   C  is  B  swollen  from  moisture. 


ARTIFICIAL   INTERRUPTION    OF    PREGNANCY 


69 


packed  with  moist  sterile  gauze.  For  this  purpose  iodoform  gauze 
is  thought  to  be  best,  but  plain  gauze  wrung  out  in  hot  saline 
will  answer.  The  vault  of  the  vagina  can  be  more  thoroughly 
packed  if  the  patient  assume  the  Sims'  position.  The  effect  of 
the  tampon  is  to  excite  labor  and  relax  the  tissues,  the  cervix  be- 
coming dilated  and  the  ovum  cast  off,  sometimes  after  a  single 
treatment.     If,  at  the  end  of  t^renty-four  hours,  no  result  has 


Fig.   14. — Four    sizes    of    tlie    Hegar    metal    dilators. 

been  obtained,  the  tampon  is  removed,  the  vagina  again  disin- 
fected, and  the  process  repeated.  If  the  ovum  still  remains  in  the 
uterus  at  the  end  of  forty-eight  hours,  other  measures  need  to 
be  employed. 

The  Use  of  Tents. — Following  the  same  aseptic  precautions,  and 
with  the  patient  close  to  the  edge  of  the  bed,  the  anterior  lip  of 
the  cervix  is  grasped  with  bullet  forceps,  and  the  portio  vaginalis 
is  drawn  into  view.    A  laminaria  plug  is  passed  into  the  cervical 


70 


THE    SURGICAL   PROCEDURES 


canal  and  left  to  swell  from  the  moisture  it  absorbs.    The  device 
is  nsually  four  or  five  centimeters  long,  and  is  introduced  by  means 


Fig.    IS. — Dilating    the    cervical    canal    with 
the   Hegar   metal    dilator. 


Fig.    16. — Puncturing  catheter. 


of  a  sharp-pointed  instrument  stuck  in  the  tent,  or  by  any  other 
device  that  will  hold  it  securely.     A  loop  of  thread  attached  to 


ARTIFICIAL   INTERRUPTION    OF   PREGNANCY  71 

the  outer  end  of  the  tent  is  tied  to  a  strip  of  gauze  packed  loosely 
about  the  cervix.  Within  twenty-four  hours  the  canal  should 
admit  the  finger.     (Fig.  13.) 

Dilatation  by  Means  of  Heg-ar's  Metal  Dilators. — This  is  accom- 
plished by  passing  into  the  cervical  canal  a  series  of  graduated 
metallic  sounds,  beginning  with  one  wdiich  will  readily  enter,  fol- 
lowed by  others  of  increasing  size.  The  last  one  may  be  as  large 
as  the  finger.     (Figs.  14  and  15.) 

Rupturing-  the  Amnion. — Puncturing  the  amniotic  sac  as  a 
means  of  inducing  labor  is  applicable  only  in  hydramnion.  The 
anterior  lip  of  the  cervix  is  grasped  with  bullet  forceps,  and  a 
sound  is  passed  through  the  canal  into  the  amnion.  If  the  cer- 
vix is  patulous,  a  trocar  can  be  used  instead  of  a  sound.  (Fig. 
16.) 

None  of  the  aforementioned  methods  of  inducing  abortion  is 
always  successful.  The  A^aginal  tampon  is  worth  temporizing 
with  because  of  its  safety  and  ease  of  application.  Tents  have 
fallen  into  disuse  as  unsurgical,  and  are  seldom  employed.  Punc- 
ture of  the  amnion  disturbs  the  growth  of  the  ovum,  but  some- 
times the  process  of  casting  off  the  arrested  life  is  slow  and  un- 
certain. Especially  is  this  true  if  the  puncture  be  made  early 
in  pregnancy,  or  when  the  amount  of  fluid  is  small.  So,  this 
method  is  of  doubtful  value  except  in  cases  of  acute  hydramnion. 
Only  if  actual  labor  begins  and  continues  will  the  uterus  empty 
itself;  otherwise,  it  will  be  necessary  to  comijlete  the  process 
instrumentally. 

In  deciding  which  method  to  use,  one  must  consider  the  cir- 
cumstances of  the  case,  and  the  advisability  of  doing  it  rapidly 
or  slowly ;  and,  quite  as  important,  one  should  consider  one 's 
own  preferences  and  skill.  But  under  all  circumstances,  no 
matter  which  method  is  folloAved,  the  most  painstaking  asepsis 
is  to  be  observed,  and  every  risk  of  infection  avoided. 

To  bring  about  premature  birth  in  the  later  months  of  preg- 
nancy, the  essential  thing  is  to  incite  labor;  and  the  simpler  the 
method,  so  long  as  it  proves  effectual,  the  better. 


72  THE    SURGICAL   PROCEDURES 

METHODS  OF  INDUCING  PREMATURE  BIRTH 

The  Prolonged  Vaginal  Douche. — Several  quarts  of  hot  water 
are  given  every  thi-ee  or  four  hours,  the  stream  being  directed 
into  the  anterior  fornix  of  the  vagina  and  against  the  cervix. 


■    Fig.    17. — Introducing  the  bougie.      (Kraus's   method   of  inducing   labor.) 

After  repeating  the  treatment  several  times,  labor  may  begin; 
but,  should  it  not,  the  procedure  is  not  without  good  effect, 
since  it  relaxes  the  tissues,  lessens  the  pain,  and  shortens  the 
stage  of  cervical  obliteration. 


ARTIFICIAL    INTERRUPTION    OF    PREGNANCY 


73 


Metreurysis.— When  no  particular  haste  is  de- 
manded, the  use  of  hydrostatic  bags  is  a  very  satis- 
factory means  of  inducing  premature  labor.  Be- 
fore the  bag  can  be  passed  into  the  uterus,  however, 
the  cervical  canal  must  be  open  enough  to  admit  the 
finger,  which  means  that  some  preliminary  dilata- 
tion, either  spontaneous  or  artificial,  must  be  ef- 
fected. When  this  degree  of  dilatation  has  taken 
place,  the  rubber  balloon  is  rolled  into  compact  form 
and  introduced  within  the  uterine  cavity.  There 
are  special  forceps  made  for  holding  the  metreuryn- 
ter but  the  ordinary  gynecologic  dressing  forceps 
answers  the  purpose  well.  The  anterior  lip  of  the 
cervix  is  secured  with  a  vulsellum  forceps,  and  the 
balloon  cautiously  pushed  through  the  canal,  direct- 
ing it  backward  between  the  amnion  and  the  uterine 
Avail.  The  bag  is  then  distended  with  water,  and 
traction  is  made  on  the  connecting  tube,  either  with 
the  hand  or  by  means  of  a  light  weight  allowed  to 
hang  over  the  side  of  the  bed.  When  labor  is  well 
started,  the  bag  should  be  removed,  especially  if  a 
living  child  is  expected,  for  it  must  ever  be  borne 
in  mind  that  premature  infants  bear  obstetric  pro- 
cedures badly.  A  spontaneous  birth  is  greatly  to 
their  advantage.  After  labor  has  surely  begun,  it 
may  be  left  to  progress  naturally. 

The  Bougie. — The  manner  of  introducing  the 
bougie  is  not  unlike  that  of  introducing  the  metre- 
urynter. The  patient  is  brought  to  the  edge  of  the 
bed,  the  vagina  opened  with  the  speculum,  the  cer- 
vix exposed  to  view,  and  the  bougie  passed  into  the 
uterus.     (Fig.  17.) 

There  are  several  varieties  of  bougies  recom- 
mended, the  most  common  of  which,  and  the  most 
readily  obtained,  is  one  made  of  linen,  flexible  and 
smooth.  No.  18  is  the  size  generally  used.  After  its  proper  ster- 
ilization, the  instrument  is  passed  into  the  uterine  cavity,  care 
being  taken,  as  with  the  metreurynter,  not  to  rupture  the  sac. 
(Fig.  18.) 


i- — : 


Fig.   18.— 
Knapp's    elas- 
tic  metal 
bougie. 


74  THE    SURGICAL    PROCEDURES 

It  is  desirable  to  direct  tlie  bougie  along  the  median  line  pos- 
teriorly, going  as  far  upward  as  possible,  and  keeping  between 
the  membranes  and  the  uterine  walls :  but,  on  account  of  its 
flexibility,  one  can  not  be  sure  of  the  course  it  pursues.  If  a 
contraction  occurs  during  its  introduction,  the  procedure  is  in- 
terrupted until  the  uterus  again  relaxes.     (Fig.  19.) 

Before  beginning  the  operation,  one  should  try  to  fix  the  site 
of  the  placenta,  so  that,  in  introducing  tlie  liougie,  it  may  be 
passed  to  the  opposite  side.  It  may  not  ah\ays  be  possible  to  do 
this,  but  when  it  is,  it  is  an  advantage.  A  helpful  observation 
when  trying  to  make  out  the  placental  insertion  is,  that  when 
the  organ  is  situated  posteriorly,  the  tubes  and  ligaments  are 
crowded  to  the  front :  and,  conversely,  when  it  lies  anteriorly, 
the  tubes  and  ligaments  are  pushed  backward,  and  lie  in  the 
flanks  of  the  patient.  The  area  in  which  the  uterine  souffle  can 
best  be  heard  is  sometimes  an  aid  in  determining  this  relation. 

If,  in  passing  the  bougie,  a  part  of  the  placenta  becomes  de- 
tached, as  known  by  the  appearance  of  blood,  the  instrument 
should  be  partly  withdrawn  and  started  in  a  new  direction. 
When  once  in  place,  it  is  held  there  by  a  vaginal  tampon. 

Puncturing-  the  Amnion. — The  patient  is  placed  in  the  dorsal 
position,  knees  flexed,  parts  disinfected,  and  the  vagina  opened 
by  either  a  Simons'  or  an  Edebohls'  speculum.  "With  the  cervix 
thus  exposed,  a  slim  dressing  forceps,  a  sound,  or  a  trochar  is 
guided  through  the  canal  into  the  amniotic  cavity.  As  much  as 
50  to  100  c.c.  of  fluid  should  come  aAvay.  If  less  than  this 
amount  is  removed,  pregnancy  may  not  be  interrupted.  The 
operation  itself  is  simple,  but  it  can  prove  serious  to  the  child 
through  the  prolapse  of  the  cord,  which  is  favored  by  the  un- 
timely discharge  of  amniotic  fluid.  If  the  head  of  the  child 
presents,  the  accident  is  not  so  likely  to  occur,  since  the  head 
more  readily  enters  the  superior  strait,  and  thereby  prevents 
the  cord  from  falling  in  front  of  it. 

Dilatation  with  the  Branched  Instruments. — Dilatation  may  be 
accomplished  in  a  much  shorter  time  with  the  Leavitt  dilator 
than  by  any  of  the  methods  above  described.     The  procedure  is 


ARTIFICIAL   INTERRUPTION    OF    PREGNANCY 


75 


simple,  rapid,  and  surgical.  (See  page  84.)  This  and  similar 
methods  of  dilatation  are  of  special  advantage  in  dealing  with 
severe  internal  diseases,  such  as  tuberculosis,  grave  heart  lesions, 
etc.,  for  in  such  disturbances  a  longer  process  adds  greatly  to  the 
danger  from  the  affection. 


Fig.    19. — Kraus's    method    of    inducing    labor.      A    bougie    has    been    passed    between    the 
amnion    and    the    uterine    wall    posteriorly. 


The  Vaginal  Cesarean  Se'ction. — The  vaginal  section,  like  the 
above  method,  is  of  service  when  rapid  delivery  is  of  importance. 
Pregnancy  can  be  ended  immediately  by  it,  and  the  uterus  emptied 
without  the  patient  undergoing  the  process  of  labor.  (See  chap- 
ter on  Cesarean  Section,  page  242). 


76  THE    SURGICAL   PROCEDURES 

PROGNOSIS 

The  prognosis  in  artificial  interruption  of  pregnancy  depends 
largely  on  the  indication  demanding  the  operation  and  the  condi- 
tions under  which  it  is  undertaken.  For  the  mother  the  chief 
danger  is  that  of  infection.  The  manipulations  Avithin  the  par- 
turient tract,  together  with  the  prolonged  and  artificial  process 
of  ridding  the  uterus  of  a  perfectly  natural  growth  before  its 
time,  involve  no  inconsiderable  risk.  While  it  was  formerly  a 
much  more  dangerous  undertaking  because  of  sepsis,  it  is  now 
possible  to  carry  out  the  procedure  with  comparative  safety.  Out 
of  2,200  cases  reported  by  one  large  European  clinic,  there  were 
only  13  deaths  from  infection. 

Besides  the  risk  of  infection  the  procedure  may  be  the  occasion 
of  a  cervical  laceration;  but  this  is  more  a  fault  of  technic  than 
of  conditions.  Conditions  do  not  often  demand  haste,  and  never 
undue  force.  Even  with  the  Bossi  dilator  one  can,  with  caution, 
dilate  the  cervix  without  injury;  and,  just  as  truly,  it  is  possible 
for  an  operator  to  do  extensive  harm  with  such  innocent  objects 
as  his  fingers  or  a  rubber  bag. 

The  prognosis  for  the  child  comes  into  consideration  only  in 
the  last  weeks  of  pregnane}^;  and  even  then  one  may  have  to 
consider  whether  a  viable  child  should  not  be  sacrificed  in  the 
interest  of  the  mother.  And  surel}^,  with  only  a  slight  chance  of 
saving  its  life,  the  mother's  life  should  not  be  jeopardized.  A 
prognosis  under  such  circumstances  must  be  very  guarded.  A 
live  child  is  not  the  only  thing  to  be  desired:  it  must  be  viable. 
To  be  born  only  to  breathe  a  few  hours,  does  not  count  for  much. 
A  whole  year  must  elapse  before  we  can  call  such  children  safely 
past  the  dangers  of  their  immaturity.  In  the  2,200  cases  men- 
tioned above,  1,721  children  were  alive  when  born,  of  whom 
1,380  lived  until  discharged  with  their  mothers;  but  only  81.2  per 
cent  of  these  survived  a  whole  year. 


CHAPTER  IV 
THE  ARTIFICIAL  DILATATION  OP  THE  CERVIX 

The  first  stage  of  labor,  or  period  of  cervical  dilatation,  repre- 
sents a  counteraction  of  push  and  pull.  The  unruptured  amniotic 
sac,  or,  if  ruptured,  the  advancing  part  is  pushed  like  a  wedge 
into  the  cervix  by  the  squeezing  process  going  on  in  the  uterus. 
A  passive  yielding  of  the  cervical  tissue  is  the  result.  The  arti- 
ficial methods  of  opening  the  canal,  which  most  resemble  this 
physiologic  process,  are  (1)  traction  on  the  fetus  made  by  attach- 
ing a  weight  to  it,  and  (2)  the  use  of  the  metreurynter  similarly 
weighted.  A  more  rapid  dilatation  can  be  accomplished  with  the 
fingers,  the  branched  dilator,  the  forcible  extraction  of  the  child, 
or,  more  rapidly  still,  by  incising  the  cervix.  The  formidable 
procedure  of  vaginal  cesarean  section,  which  can  hardly  be  clas- 
sified as  one  of  the  dilating  operations,  is  also  designed  to  ac- 
complish the  same  end.  The  application  of  these  various  methods 
is  indicated  when,  for  any  reason,  it  becomes  expedient  to  open 
the  cervix  artificially. 

Weighted  Traction  Applied  to  the  Fetus. — We  possess  no  means 
of  applying  slow  and  effective  traction  to  the  living  fetus  if  it 
presents  by  the  head ;  but,  if  it  is  dead,  and  the  cervix  dilated 
to  the  size  of  a  half  dollar,  its  scalp  may  be  fixed  in  the  grasp  of 
a  strong  pair  of  toothed  forceps  to  which  a  weight  of  two  or 
three  pounds  is  attached  and  allowed  to  hang  over  the  side  of 
the  bed.  In  this  Avay  continuous  traction  may  be  exerted  for 
several  hours,  and  the  head  constantly  drawn  into  the  cervical 
canal ;  at  the  same  time  uterine  contraction  thereby  is  stimulated. 

If  the  foot  presents,  continuous  traction  may  be  made,  and 
with  relative  safety,  on  the  living  child,  because  of  the  conven- 
ient object  that  offers  itself  to  take  hold  of.  Mechanically,  this 
is  an  advantage,  serving  the  excellent  purpose  of  dilating  from 
within   outward ;   but   the   risks   are    greatly   increased   for   the 

77 


78 


THE    SURGICAL   PROCEDURES 


child  owing  to  the  difficulty  experienced  in  delivering  its  largest 
and  most  important  part  last. 

Dilatation  by  Means  of  the  Hydrostatic  Bag-.— The  action  of 
the  hydrostatic  bag  is  twofold:  it  stimulates  uterine  contractions 
and  dilates  at  the  same  time,  thus  simulating  very  closely  the 
normal  first  stage  of  labor.     The  principal  models  of  the  instru- 


Fig.   20 — Braun's    rubber 
balloon. 


Fig,   21. — Two   sizes   of   \'oorhees'   hydrostatic    bags. 


ment  are  the  Voorhees,  Tarnier,  Braun,  and  Champetier  de 
Ribes.  There  are  many  others,  but  the  technic  of  their  use  is 
practically  the  same.  Owing  to  the  limitations  of  their  disten- 
sibility  several  sizes  should  be  at  hand.  (Figs.  20,  21,  and  22.) 
The  technic  of  hydrostatic  dilatation  is  one  of  introducing  into 


ARTIFICIAL    DILATATION    OP    THE    CERVIX 


79 


the  uterus  through  the  cervical  canal  a  collapsed  bag  which  is 
withdrawn  in  a  state  of  distention.     (Fig.  23.)     One  or  more  of 


Fig.   22. — Three   sizes   of   the    Barnes    fiddle-shape   hydrostatic   elastic   dilators. 


Fig.   23. — Hydrostatic   dilator   (small    size)    in  its  collapsed  state,   held  with   a  dressing  for- 
ceps  and   ready  to   be   introduced   into   the   uterine  cavity. 

these  with  a  speculum,  forceps  (for  grasping  the  portio  vaginalis), 
a  metal  syringe  of  100  to  150  c.c.  capacity,  and  such  other  in- 


80 


THE    SURGICAL   PROCEDURES 


struments  as  may  be  needed,  are  sterilized  in  the  usual  way. 
The  patient  is  placed  cross-wise  on  the  bed,  and  the  legs  supported. 
Cleansing  and  disinfection  of  the  parts  must  be  as  exact  as  in 
other  surgical  procedures.     (Fig.  24.) 

In  using  the  Tarnier  balloon  one  simply  shoves  it  through  the 
cervix  with  its  metal  tube,  and  injects  it  slowly  and  cautiously 
with  a  warm  sterile  solution.  After  it  is  distended  to  the  de- 
sired degree,  the  stopcock  is  closed  or  the  tubing  clamped.     The 


Fig.   24. — Introducing   the   hydrostatic    dilator. 

larger  sizes  may  be  rolled  lengthwise  and  introduced  by  the 
instrument  designed  for  the  purpose,  or,  which  answers  quite  as 
Avell,  with  a  pair  of  curved  dressing  forceps.  Before  introducing 
any  of  these  devices  one  should  have  previously  tested  its  capacity 
and  competency;  otherwise,  one  might  inject  too  little  or  too 
much  water,  or  find  that  the  balloon  leaks.  There  is  an  ele- 
ment of  uncertainty  about  rubber  which  makes  its  use  very  un- 
satisfactory.    (Figs.  25,  26,  and  27.) 


ARTIFICIAL    DILATATION    OF    THE    CERVIX 


81 


After  the  metreurynter  lias  been  put  in  position  and  distended, 
a  cord  is  tied  to  the  tube  and  brought  over  the  side  of  the  bed. 
A  weight  is  attached  that  corresponds  to  the  weigh  of  the  water 
in  the  balloon,  so  that  the  number  of  grams  in  the  Aveight  of  the 
one  will  equal  the  number  of  cubic  centimeters  in  the  capacity 
of  the  other.     (Fig.  28.) 

When  the  amniotic  sac  is  still  intact,  the  metreurynter  will 
adjust  itself  betAveen  it  and  the  uterine  wall  and  may,  in  conse- 


Fig.   25. — The   dilator   in   place,    now   being   injected. 


quence,  push  the  presenting  part  to  one  side.  In  conditions  of 
overdistention,  as  in  hydramnion  or  twins,  it  is  almost  neces- 
sary to  rupture  the  sac  before  introducing  the  metreurynter ; 
otherAvise,  there  might  be  danger  of  rupturing  the  uterus.  Also 
in  low  attachment  of  the  placenta,  the  sac  should  be  ruiotured;  for, 
if  it  is  not,  the  distended  bag  Avill  occasion  serious  hemorrhage. 
As  the  metreurynter  distends,  the  advancing  part  is  pushed 
upward  or  to  one  side,  the  balloon  itself  comes  to  occupy  the 


82 


THE   SLTRGICAL   PROCEDURES 


place  of  the  presenting  part,  or,  perhaps,  materially  alters  it. 
Usually,  labor  begins  within  the  first  half-hour.  The  average 
time  taken  to  effect  the  complete  opening  of  the  canal  being 
about  six  or  seven  hours,  depending  on  the  stage  of  pregnancy, 
parity,  etc.,  of  the  patient.  It  may  help  to  let  some  of  the  Avater 
out  of  the  metreurynter,  thus  permitting  it  to  insinuate  itself 
more  effectually  into  the  canal.  Later  the  water  may  be  replaced 
and  the  bag  again  distended.    The  process  of  dilatation  may  also 


Fig.   26. — The   dilator   in  position   and   distended   with  water,   ready   to   begin   dilatation   by 

means   of  traction. 


be  hastened  by  making  stronger  traction  on  the  tube  either  by 
pulling  with  the  hand  or  by  adding  to  the  weight  attached. 

When  dilatation  has  reached  the  full  size  of  the  metreurynter, 
which  is  manifest  by  its  coming  away,  an  examination  should  im- 
mediately be  made  to  ascertain  whether  or  not  the  position  of 
the  child  has  changed.  If  everything  is  found  favorable,  labor 
is  allowed  to  go  on  naturally. 

Manual  Dilatation.— In  the  multipara  it  is  often  possible  to 
pass  a  finger,  sometimes  tAvo  fingers,  through  the  cervix  before 


AfeTIFICIAL   DILATATION    OF    THE    CERVIX 


83 


labor  begins,  so  that  combined  version  may  be  attempted;  but 
with  the  ]3rimipara  it  is  generally  impossible  to  accomplish  much 
dilatation  with  the  fingers,  and  unless  the  os  uteri  be  easily 
dilatable,  the  manual  method  is  not  to  be  recommended. 

Dilatation  by  Means  of  Parallel  Levers. — Metal  instruments 
with  two  or  more  parallel  blades  or  arms,  made  to  separate  at 
their  distal  end  by  some  sort  of  leverage  applied  with  the  hand, 


Fig.  27. — Hydrostatic  dilatation  of  the  cervix,  introducing  the  collapsed  metreurynter. 
The  posterior  wall  of  the  vagina  is  retracted,  and  the  anterior  lip  of  the  cervix  drawn 
upward   and   forward. 


elastic  band,  or  a  screw  device,  are  of  considerable  utility.  The 
criticism  made  against  their  use  is,  that  they  sometimes  do  dam- 
age; but  can  not  this  be  said  of  any  instrument? 

The  Bossi  dilator  (Fig.  30)  is  a  most  ingenious  and  effective 
instrument  for  opening  the  cervix,  and  when  cautiously  em- 
ployed is  no  more  harmful  than  any  contrivance  or  method 
intended  to  dilate  rapidly.     For  a  number  of  years  it  enjoyed 


84 


THE    SURGICAL   PROCEDURES 


great  popularity,  especially  in  Europe,  but  other  means  of  dilat- 
ing the  canal  have  for  the  time  superseded  it.  One  disadvantage 
of  the  Bossi  dilator  is.  that  all  four  blades  must  be  introduced 
at  the  same  time.  This  is  not  always  easy  or  even  possible  when 
the  cervix  is  tightly  contracted;  it  then  becomes  necessary  to 
begin  the  dilatation  with  a  smaller  two-bladed  instrument.  After 
the  canal  has  been  opened  to  the  width  of  two  fingers  a  metal 
cap  with  a  broad  surface  is  slipped  over  the  tip  of  each  lever  of 
the  Bossi  dilator  before   carrying  dilatation  to   its   completion. 


Fig.   2S. — Champetier   de   Ribes   metreurynter   in   position. 

The  surfaces  coming  in  contact  with  the  canal  are  corrugated  to 
prevent  slipping,  and,  when  spread  apart,  the  blades  curve  out- 
ward in  a  way  to  favor  their  retention  within  the  uterus.  The 
instrument  is  made  with  a  pelvic  curve,  and  has  an  index  show- 
ing in  centimeters  the  degrees  of  dilatation  obtained  (Fig.  29). 
The  Leavitt  Dilator  and  Method  of  Use. — Some  twenty  years 
ago  I  invented  an  instrument  (Fig.  31)  for  dilating  the  cervix 
which  has  the  advantage  of  being  simple  in  construction  and 
easy  of  manipulation.  It  consists  of  four  levers,  and  a  handle 
having  a  large  disc  at  one  end  and  a  small  one  at  the  other. 


ARTIFICIAL   DILATATION    OP    THE    CERVIX 


85 


Each  blade  is  notched  near  its  middle,  ^vhich  fits  into  a  suitable 
depression  on  the  edge  of  the  disc.     The  ends  of  the  levers  (the 


Fig.   29. — Bossi  dilator  in  operation. 


blade  part)  are  designed  to  enter  the  cavity  of  the  uterus  only 
so  far  as  may  be  necessary  to  do  the  work  required ;,  the  gynecic 
end  is  long  and  slender,  the  obstetric  end  short  a^ud,  broad.    When 


86 


THE    SURGICAL   PROCEDURES 


in  position,  dilatation  may  be  carried  on  by  compressing  the 
proximal  ends  of  the  blades  with  the  hand  alone,  with  a  rubber 
band  alone,  or,  what  is  more  practical,  with  both  the  hand  and 


Fig.    30. — Bossi  metal  dilator. 


Fig.    31. — Leavitt   metal   dilator. 


the  rubber  at  the  same  time,  the  one  supplementing  the  other.  If 
intermittent  pressure  is  desired,  opposing  levers  can  be  com- 
pressed even  Avhile  the  band  is  doing  its  part  of  the  work. 

There  are  no  screws  to  adjust,  no  hinges  or  joints  to  become 


ARTIFICIAL    DILATATION    OF    THE    CERVIX  87 

rusty,  no  detachable  parts  to  get  lost.  There  are  only  five 
pieces  to  the  Avhole  instrument,  and  they  are  plain  and  easily 
cleaned.  It  is  self-retaining  as  soon  as  the  second  blade  is  in 
position.  It  is  light,  yet  powerful  enough  to  do  tAvice  the  work 
demanded  of  it.  It  does  not  obstruct  the  field  of  operation ;  the 
process  of  dilatation  can  be  closely  watched,  the  parts  sponged, 
and  the  presenting  part  palpated — all  between  the  blades  of  the 
instrument.  If  the  occasion  demands  greater  haste,  multiple 
incisions  after  the  method  of  Diihrssen  can  be  made  between 
the  blades. 

In  using  the  instrument  the  patient  is  brought  to  the  edge  of 
the  table  and  the  knees  separated;  and  the  posterior  wall  of  the 
vagina  is  depressed  with  a  speculum.  The  Edebohls'  speculum 
is  very  serviceable,  as  it  is  self -retaining  Avhen  weighted ;  besides, 
it  serves  to  relax  the  perineal  tissues.  The  first  lever  of  the 
dilator  is  introduced  up  to  the  projection  on  its  blade.  On 
this  lever  is  placed  the  fulcrum  of  the  handle,  the  notch  of  which 
fits  into  the  notch  of  the  lever.  A  second  lever  is  similarly  in- 
troduced opposite  to  the  first.  A  small  sterile  rubber  band  is 
then  slipped  over  the  free  ends  of  the  levers,  not  for  purposes  of 
dilatation,  but  simply  to  keep  the  levers  in  place.  As  each  of  the 
two  remaining  levers  is  introduced  and  adjusted  to  the  handle, 
the  band  is  made  to  include  it  in  its  grasp.  When  all  four 
levers  are  in  position,  active  dilatation  is  begun  and  maintained 
by  a  strong  rubber  band  wound  about  the  proximal  ends  of  the 
levers.  As  dilatation  progresses,  and  the  ends  of  the  levers  are 
brought  together,  the  band  should  from  time  to  time  be  reapplied. 
(Fig.  32.) 

Dilatation  should  be  carried  on  slowly.  It  is  rapid  enough  if 
in  the  course  of  every  two  or  three  minutes  it  increases  half  a 
centimeter  in  diameter.  Bossi  himself  takes  an  hour  or  more 
for  the  operation,  and  continually  awaits  the  assistance  of  natural 
labor  pains.  If  one  forces  the  process  so  that  the  tissues  do  not 
have  sufficient  time  to  stretch,  there  is  danger  of  lacerating  the 
cervix.  Cases  have  been  reported  where,  with  the  Bossi  dilator, 
the  tissues  have  been  torn  beyond  the  vault  of  the  vagina  into  the 
parametrium.  To  avoid  such  injuries  the  instrument  should  be 
used  in  first  births  only  when  the  cervix  has  become  obliterated 


THE    SURGICAL   PROCEDURES 


Fig.  32.— Dilatation  of  the  cervix  with  the  Leavitt  dilator  The  smaller  end  of  the 
fevers  and  the  smaller  fulcrum  of  the  handle  are  being  used.  The  amount  of  dilata- 
tion to  be  gained  is  approximately  one-half  as  much  as  can  be  accomplished  by  reversing 
the  levers  and  handle. 


ARTIFICIAL    DILATATION    OF    THE    CERVIX  89 

and  only  the  external  os  remains  to  be  opened,  or  when  in  the 
multipara  the  whole  cervix  is  relaxed  and  dilatable.  When  suf- 
ficiently opened,  the  forceps  may  be  applied ;  or,  if  the  child  is 
dead,  craniotomy  performed.  It  is  doubtful  if  the  uterine  sup- 
ports become  seriously  injured  thereby. 

Dilatation  Through  Forcible  Extraction  of  the  Child, — In  in- 
complete dilatation  of  the  cervix  the  forceps  may  be  applied  to 
the  advancing  head,  and  the  process  hastened  by  means  of  trac- 
tion, especially  in  a  multipara  with  dilatable  soft  parts.  The 
same  procedure  may  be  carried  out  in  first  births,  but  one  must 
bear  in  mind  the  greater  resistance  of  the  tissues  and  the  in- 
creased risk  of  laceration;  also  that,  not  only  the  external  os,  but 
the  internal,  as  well,  must  be  dilated,  since  the  latter  offers  as 
great  resistance  as  the  former.  In  a  case  permitting  cranioclasis, 
delivery  may  be  effected  if  the  cervix  has  dilated  to  the  size  of 
a  silver  dollar. 

Dilatation  may  also  be  secured  through  forcible  extraction  by 
the  feet,  whether  they  come  down  spontaneously  or  are  brought 
down  purposely.  The  extremity  furnishes  an  exceptionally  good 
handle,  though  it  must  not  be  pulled  hard  enough  to  cause  injury 
to  the  child.  One  must  also  bear  in  mind  the  wedge-like  action 
involved,  and  give  ample  time  for  dilatation  to  take  place.  If 
incomplete,  the  child's  arms  become  extended  above  the  head, 
and  not  only  is  valuable  time  lost  in  freeing  them,  but,  after 
bringing  them  down,  there  is  the  further  complication  of  an  un- 
dilated  cervix  clamping  itself  so  tightly  about  the  baby's  neck 
that  in  forcing  the  delivery  the  cervix  is  likely  to  be  seriously 
torn;  besides,  the  danger  from  asphyxiation  is  greatly  increased. 
(See  chapter  on  Breech-birth,  page  141.) 

Cervical  Incisions. — In  complete  effacement  of  the  cervix  the 
external  os  alone  remaining  undilated,  resistance  may  be  over- 
come by  means  of  incisions.  These  are  made  to  extend  up  to  the 
vaginocervical  attachment,  and  give  ample  diameter  for  the 
child  to  pass,  unless  the  supravaginal  part  of  the  cervix  or  the 
vaginal  vault  itself  offers  resistance.  The  thinner  and  more 
drawn  out  these  tissues,  the  higher  the  section  can  safel}^  be 
carried.     The  cases  best  suited  for  the  operation  are  those   of 


90  THE    SURGICAL   PROCEDURES 

first  births  with  the  head  presenting.  The  spontaneous  oblitera- 
tion of  the  cervix  leaves  only  a  paper-thin  os  nteri  to  cut. 

The  technie  is  simple.  After  carefully  preparing  the  patient, 
the  mouth  of  the  uterus  is  exposed,  and  the  incisions  made ;  or 
they  may  be  made  entirely  under  the  sense  of  touch.  The  ring 
of  tissue  is  cut  in  the  median  line  posteriorly  and  on  both  sides 
up  to  the  posterior  vault  of  the  vagina.  If  these  three  incisions 
appear  insufficient,  another  may  be  made  anteriorly,  though  one 
should  be  more  solicitous  about  this  last  since  a  laceration  may 
cause  it  to  continue  on  into  the  bladder.  If  one  depend  entirely 
upon  the  sense  of  touch,  the  Avhole  hand  is  passed  into  the  vagina; 
one  finger  is  made  to  lie  between  the  head  of  the  child  and  the 
OS,  another  just  outside  on  the  portio  vaginalis ;  the  cervix  close 
to  the  palmar  surface  may  then  be  safely  cut.  Generally  there 
is  but  little  bleeding,  and  unless  the  incision  is  extended  by 
laceration,  suturing  is  not  necessary.  Delivery  can  usually  be 
completed  with  the  forceps.  If  turning  and  extraction  is  under- 
taken, the  danger  of  an  extending  laceration  is  increased. 

Instead  of  three  deep  incisions,  numerous  notches  half  a  centi- 
meter long  may  sometimes  be  employed  to  equal  advantage. 

The  Vaginal  Cesarean  Section. — This  is  a  much  more  formid- 
able procedure  and  is  discussed  further  on. 

Remarks 

Dilatation  of  the  cervix  is  indicated  in  about  3  per  cent  of  all 
cases.     The  operation  is  practically  without   danger. 

Because  of  the  injuries  sustained,  and  the  inviting  field  they 
offer  for  inoculation,  the  more  rajjid  the  dilatation,  the  more 
dangerous  the  operation  becomes. 

If  the  case  demands  haste,  one  may  take  greater  risks,  as,  for 
example,  in  eclampsia  and  in  heart  and  lung  diseases. 

A  matter  of  a  few  minutes  seldom  results  seriously.  It  would 
hardly  be  advisable  to  resort  to  the  elastic  balloon  in  the  pres- 
ence of  a  rigid  os  uteri.  A  vaginal  cesarean  section  might  save 
a  life. 

The  choice  of  procedures  must  depend  on  the  exigencies  of 
the  case. 

The  principal  indications  for  undertaking  the  rapid  dilatation 


ARTIFICIAL   DILATATION    OF    THE    CERVIX  91 

of  the  cervix  are  eclampsia,  serious  affections  of  the  heart  and 
lungs,  premature  detachment  of  the  normally  situated  placenta, 
and  the  infectious  fevers. 

One  is  "warranted  in  choosing  the  more  rapid  methods,  if,  in 
the  interest  of  the  child,  they  can  be  carried  out  Avithout  increas- 
ing the  dangers  for  the  mother. 

Placenta  previa  offers  an  important  contraindication  to  any 
form  of  dilatation  for  the  obvious  reason  that  the  procedure 
lacerates  tissues  which  bleed  profusely;  but  when  it  is  done  it 
should  be  done  rapidly,  and  the  dilatation  carried  to  the  limit. 

OOLPEURYSIS 

A  few  words  may  be  added  with  reference  to  the  hydrostatic 
bag  as  used  in  the  vagina:  (1)  When  distended  in  the  anterior 
fornix,  it  excites  the  uterus  to  greater  activity;  (2)  when  the 
advancing  part  of  the  child  does  not  sufficiently  close  the  pelvic 
girdle,  as,  for  example,  in  cross-births,  foot  presentations,  and 
contracted  pelves,  the  amniotic  fluid  is  forced  in  such  quantities 
into  the  lower  pole  of  the  fetal  ovoid  that  the  sac  stands  in  great 
danger  of  becoming  prematurely  ruptured,  which  would  not  only 
delay  birth,  but  would  add  to  the  difficulty  of  performing  some 
of  the  simpler  operations  of  delivery.  By  means  of  the  col- 
peurynter  sufficient  counterpressure  may  thus  be  afforded  to  pre- 
vent the  sac  from  rupturing. 

It  is  also  of  use  in  placenta  previa,  especially  while  the  patient 
is  being  conveyed  to  the  hospital.  It  acts  as  a  tampon,  taking 
the  place  of  vaginal  packing. 

In  first  labors  the  vagina  is  usually  so  tightly  contracted  that 
the  hand,  if  for  any  reason  it  becomes  necessary  to  introduce  it, 
can  be  passed  only  with  great  difficulty  and  with  more  or  less 
injury  to  the  parts.  To  prepare  the  canal  for  such  an  ordeal,  the 
colpeurynter  serves  a  very  useful  purpose.  Inserted  into  the 
vagina,  distended  with  fluid,  and  then  slowly  withdrawn,  the  tis- 
sues become  so  relaxed  after  several  repetitions  of  the  treatment 
that  manual  investigations  and  maneuvers  can  be  carried  on 
without  doing  serious  damage. 

Technic  of  Colpeurysis. — The  bag,  a  curved  dressing  forceps, 


92  THE   SURGICAL   PROCEDURES 

and  a  piston  syringe  of  100  to  150  c.c.  capacity  are  sterilized. 
The  patient  and  operator  are  properly  disinfected.  The  col- 
peurynter  is  folded  lengthwise  and  grasped  with  the  forceps  or 
with  the  fingers  of  the  right  hand.  AVith  the  left  hand  separating 
the  labia,  the  balloon  is  pushed  high  up  in  the  vagina  and  held 
there  while  an  assistant,  usually  a  nurse,  injects  it  with  a  mild 
antiseptic  solution.  When  fully  distended,  the  tubing  is  clamped 
with  an  artery  forceps,  and  the  patient  returned  to  bed.  If  not 
expelled  by  the  end  of  six  hours,  the  bag  should  be  emptied  and 
removed,  and  an  examination  made  to  see  if  the  obstetric  situa- 
tion has  altered.  The  one  treatment  ought  to  be  long  enough  to 
accomplish  the  end  sought,  but  the  colpeurynter  may  be  intro- 
duced a  second  time,  and  left  another  six  hours.  A  longer  period 
will  cause  serious  injury  to  the  epithelium  of  the  vaginal  mucous 
membrane. 

If  the  bag  is  used  for  the  purpose  of  regulating  labor  pains, 
the  effect  is  not  always  immediate ;  it  may  take  an  hour  or  more, 
or  it  may  even  fail  altogether.  Upon  its  spontaneous  expulsion 
the  vagina  and  introitus  will  be  found  relaxed,  and  not  uncom- 
monly the  cervix  and  os  uteri,  as  well. 

It  is  recommended  that  the  colpeurynter  and  other  devices 
made  of  gum  rubber,  be  preserved  in  glycerine,  or,  at  least  their 
surfaces  smeared  with  this  substance,  when  they  are  put  away 
for  further  use. 


CHAPTER  V 

OPERATIONS  DESIGNED  TO   INCREASE   THE 
PELVIC  DIAMETERS 

When  the  diameters  of  the  bony  pelvis  bear  such  relation  to 
the  size  of  the  fetus  that  the  child's  head  can  not  pass  without 
endangering  the  life  of  the  mother  or  the  baby  itself,  it  is  pos- 
sible, within  certain  limits,  to  enlarge  the  pelvic  ring  sufficiently 
to  permit  of  safe  delivery.  This  increased  diameter  is  gained  by 
severing  the  pelvis  in  front,  thereby  allowing  the  ossa  innominata 
to  swing  outAvard  on  their  sacral  hinge.  The  muscles  attached 
laterally  will  not  of  themselves  act  powerfully  enough  to  do  any 
particular  harm,  but  the  forces  of  labor,  increased  by  operative 
procedure,  such  as  forceps  or  extraction,  can  cause  most  serious 
damage.  The  limit  of  relative  safety  is  reached  if  the  disunited 
pubes  is  separated  4  to  6  cm.  It  has  been  experimentally  estab- 
lished that  by  spreading  the  pelvis  apart  to  this  degree  the  con- 
jugata  vera  will  be  increased  1  or  2  cm.,  and  the  transverse 
diameter  2  or  3  cm. 

The  pelvic  widening  operations  consist  either  in  separating  the 
bony  ring  at  the  symphysis  (symphyseotomy)  or  in  sawing  it 
apart  a  little  to  one  side  of  the  symphysis  (pubiotomy). 

For  the  intelligent  understanding  of  these  operations,  and 
the  injuries  which  accompany  them,  the  folloAving  anatomic 
knowledge  is  important: 

Anatomy. — The  symphysis  is  a  fibrocartilaginous  joint  uniting 
the  two  pubic  bones  in  front,  and  has  a  distinct  synovial  cavity. 
The  superior  pubic  ligament  above  and  the  inferior  pubic  liga- 
ment below,  bind  the  bones  together.  The  internal  pubic  artery 
supplies  the  soft  parts  on  the  anterior  surface.  In  front  and 
below  is  found  a  rich  plexus  of  veins,  which  gives  off:  branches 
to  the  lower  border  of  the  os  pubis  and  its  periostium  through 

93 


94  THE    SURGICAL   PROCEDURES 

which  it  is  closely  connected  with  the  clitoris.  The  veins  sur- 
round the  clitoris,  which  is  made  fast  to  the  symphysis  by  the 
suspensory  ligament.  On  both  sides  near  the  introitus  vaginae 
close  to  the  vaginal  wall,  is  found  the  bulb  of  the  vestibule,  which 
converges  with  the  clitoris.  It  is  here  that  the  essential  connect- 
ing branch  is  found  which  unites  the  plexus  with  the  veins  of 
the  pelvic  outlet.  In  this  way  the  plexus  is  connected  with  the 
venous  plexus  of  the  vulva  and  vagina,  with  the  urethral  and 
hemorrhoidal  veins,  and  with  the  obturator  veins  and  veins  of 
the  muscles. 

On  the  posterior  surface  of  the  s^^mphysis  are  found  important 
arterial  branches  to  the  rami  of  the  pubes  and  to  the  obturator 
artery,  between  which,  oftentimes,  there  is  an  anastomosis,  the 
so-called  "funeral-wreath"  artery. 

The  bladder  lies  back  of  the  symphysis,  usually  a  little  to  the 
right  of  the  median  line,  and  somewhat  separated  from  the  pubes 
by  a  layer  of  fat  and  connective  tissues,  forming  what  is  known 
as  the  prevesical  space,  or  space  of  Retzius.  The  upper  section 
of  the  bladder  lies  closer  to  the  symphysis  and  the  pubic  bones 
than  the  lower.  The  ureters  pass  along  the  x)osterior  wall  of  the 
pubes,  but  not  in  contiguity  with  them.  The  urethra  is  sepa- 
rated from  the  arch  through  the  structure  of  the  clitoris.  Very 
few  vessels  are  to  be  found  in  the  tissues  between  the  l3ones. 

INDICATIONS  AND  PREPARATIONS 

The  only  indication  for  undertaking  am^  operation  whose  ob- 
ject is  to  increase  the  size  of  the  mother's  pelvis,  is  the  dispro- 
portion Avhich  sometimes  exists  between  her  own  osseous  struc- 
tures and  the  head  of  the  child.  If  this  disparity  is  very  marked, 
neither  symphyseotomy  nor  pubiotomy  are  indicated  at  all.  But 
should  the  history  of  former  labors  show  that  delivery  was 
effected  only  with  difficulty,  the  head  refusing  to  enter  the  su- 
perior strait,  and  should  the  measurements  show  a  moderate  de- 
gree of  contraction,  the  operation  is  one  that  may  be  considered. 
One  must  be  thoroughly  convinced,  however,  that  the  dystocia  is 
due  only  to  anatomic  disproportion,  and  that  neither  the  cervix 
nor  the  amnion  is  responsible  for  the  resistance. 

The  types  of  inadequacy  most  frequently  met  with   are  the 


INCREASING    THE   PELVIC    DIAMETERS  95 

simple  flat,  the  flat  rachitic,  the  generally  contracted,  and  the 
funnel-shaped  pelvis. 

The  competing  operations  are  the  abdominal  cesarean  section, 
craniotomy,  induction  of  premature  labor,  version,  and  the  use 
of  forceps. 

Inasmuch  as  the  operation  is  expected  to  give  the  additional 
space  required  for  the  safe  passage  of  the  child,  and  the  fact 
that  this  increase  is  safe  onlj^  to  a  certain  degree,  it  is  exceed- 
ingly important  to  know  the  exact  size  of  the  patient's  pelvis 
before  undertaking  its  separation;  and  anyone  competent  to 
perform  so  grave  an  operation  should  be  skilled  in  pelvic  men- 
suration. 

If  the  child's  head  is  of  average  size,  the  following  dimen- 
sions are  said  to  be  within  the  limits  of  utility:  in  flat  pelves  a 
true  conjugate  of  7  em.  and  upward ;  in  the  generally  con- 
tracted pelvis,  7.5  cm.  and  upAvard.  Having  these  diameters 
to  start  with,  the  separation  of  the  pubes  Avill  allow  the  head 
to  pass,  especially  since  the  severed  bones  admit  a  considerable 
portion  of  the  child's  head  into  the  gap  between  their  severed 
ends.  And  while  it  may  be  possible  in  exceptional  cases  to  de- 
liver in  even  greater  degrees  of  pelvic  contraction,  the  procedure 
is  unsafe  and  not  to  be  recommended.  Only  when  the  dispropor- 
tion is  such  that  an  increased  conjugata  vera  of  one  or  perhaps 
two  centimeters  is  sufficient,  should  pubiotomy  or  symphyseotomy 
be  undertaken.  A  true  -conjugate  below  this  Avould  be  an  indica- 
tion for  cesarean  section. 

A  second  and  equally  important  fact  to  be  determined  before 
proceeding  to  operate,  is,  that  the  child  is  alive;  otherwise  em- 
bryotomy would  be  the  proper  procedure. 

Again,  the  soft  parts  of  the  mother  should  be  yielding.  Since 
the  pubic  bones  furnish  the  chief  support  for  the  bladder,  urethra, 
and  upper  portion  of  the  vagina,  their  wide  separation  subjects 
these  structures  to  great  violence.  In  the  primipara  the  parts 
are  very  tight  and  unyielding,  and  for  this  reason  alone  pubiotomy 
and  symphyseotomy  are  not  often  performed  in  first  births. 
Severe  traumatisms  may  also  occur  in  the  multipara  if  delivery 
is  rapid;  the  labor  should  be  allowed  to  progress  spontaneously, 
or  even  retarded,  in  order  to  alloAv  the  tissues  time  to  stretch. 


96  THE    SURGICAL   PROCEDURES 

Besides  the  actual  damage  sustained,  which  may  he  very  serious 
to  the  bladder,  all  wounds  become  dangerous  in  the  presence 
of  the  lochial  discharges. 

The  birth  canal  must  be  aseptic.  If  the  general  condition  is 
good,  and  the  pulse  slow  and  strong,  one  may  undertake  the 
operation  without  much  fear;  but  with  unmistakable  signs  of 
infection,  perforation  and  cranioelasis,  even  if  the  child  is  alive, 
is  entitled  to  consideration.  One  shudders  at  the  thought  of  tak- 
ing life,  but  there  are  a  few  situations  in  obstetrics  in  which 
the  unborn  child  may  have  to  be  sacrificed  rather  than  subject 
the  mother  to  the  danger  of  losing  her  own. 

Finally,  the  operation  should  be  performed  only  in  the  hospital 
and  by  an  experienced  operator. 

SYMPHYSEOTOMY 

There  are  two  methods  of  severing  the  pubes  at  the  sym- 
physis, the  open  and  the  closed. 

The  Open  Operation. — The  vulva,  vagina,  abdominal  wall,  and 
the  inner  surfaces  of  the  thighs  are  disinfected  after  approved 
methods,  and  the  bladder  catheterized.  With  the  patient  in  the 
dorsal  position,  the  separated  knees  held  by  stirrups  or  supported 
by  assistants,  the  skin,  fat,  and  fascia  are  incised  down  to  the 
bone  transversely  over  the  symphysis.  By  blunt  dissection  the 
connective  tissue  is  freed,  and  the  bladder  and  urethra  isolated. 
Bleeding  is  only  moderate  and  easily  controlled  by  pressure. 
The  finger  is  now  pushed  to  the  under  surface  of  the  articula- 
tion, in  which  position  it  acts  as  a  guide  to  the  knife  (a  blunt- 
pointed  bistoury)  with  which  the  joint  is  severed.  Union  is  not 
always  directly  in  the  median  line,  it  may  be  deflected  to  one  or 
the  other  side.  In  going  through  the  inferior  arcuate  ligament, 
the  clitoris  is  in  danger  of  being  wounded,  and  must  be  guarded. 
The  joint  can  be  felt  to  separate,  and  care  should  be  taken  not 
to  spread  the  knees  apart  with  much  force  for  fear  of  lacerating 
the  soft  parts  overlying  the  symphysis.  The  wound  is  now 
packed  with  gauze,  an  elastic  binder  brought  around  the  pelvis, 
and  labor  allowed  to  go  on  naturally.  Spontaneous  birth  is  to  be 
expected. 


INCREASING    THE   PELVIC    DIAMETERS  97 

In  case  delivery  does  not  follow  in  due  course,  or  should  there 
arise  any  indication  for  its  immediate  termination,  further  aid 
must  be  offered.  A  small  dose  (5-7  minims)  of  pituitary  extract 
should  be  given  and  its  effect  aAvaited  before  resorting  to  for- 
ceps. Failing  then,  perforation  and  cranioclasis  become  neces- 
sary. The  chief  objection  to  the  whole  procedure  is  that  a  little 
disproportionate  force  can  do  a  great  deal  of  damage.  This  must 
constantly  be  l5orne  in  mind. 

After  labor  is  over,  the  elastic  bandage  is  removed,  the  gauze 
packing  taken  out  of  the  wound,  the  periosteum  draAvn  together 
with  catgut,  and  the  wound  closed.  Some  operators  advise  drain- 
age through  a  counterincision  in  the  labia  majora;  but  this  is 
not  necessary  if  the  operation  has  been  aseptically  performed. 
The  after-care  is  essentially  that  of  a  normal  puerperium.  A 
little  anxiety  is  felt  as  to  the  bladder  and  urethra,  and  for  the 
first  day  or  tAvo  the  patient  may  require  catheterization. 

The  Closed  or  Subcutaneous  Operation. — Through  a  small  in- 
cision made  in  the  linea  alba  the  finger  is  pushed  beyond  the 
symphysis  into  the  space  of  Retzius,  and  the  bladder  shoved  out 
of  the  way  of  harm.  With  a  small  blunt-pointed  knife  the 
cartilage  of  the  joint  is  incised  to  a  depth  of  four  to  five  centi- 
meters. A  carrier  needle  (Bumm's  or  Doderlein's)  is  entered  one 
centimeter  above  the  upper  border  of  the  clitoris,  and  directed 
downward  around  and  upward  close  to  the  symphysis,  the  point 
passing  through  the  lower  border  of  the  inferior  arcuate  liga- 
ment and  appearing  in  the  space  between  the  symphysis  and 
bladder.  A  Gigli  saw  is  now  fastened  to  the  eye  of  the  carrier, 
and  drawn  into  position  for  sawing.  Three  to  five  back-and- 
forth  movements  are  sufficient  to  sever  the  ligaments  and  carti- 
lage. The  incision  made  over  the  pubes  is  closed  and  the  patient 
put  to  bed,  and,  as  in  the  open  method,  labor  is  allowed  to 
complete  itself. 

Should  some  of  the  fibers  of  the  arcuate  ligament  still  hold,  it 
is  possible  to  sever  them  with  a  tenotome  introduced  through  the 
puncture  made  near  the  clitoris.  With  the  index  finger  of  the 
left  hand  in  the  vagina  directing  the  course  of  the  bistoury,  fiber 
by  fiber  of  the  ligament  can  be  cut. 

The  knees  are  kept  together  for  several  days,  but  outside  of 


98 


THE    SURGICAL   PROCEDURES 


the  dressing  of  the  wound  itself  no  further  bandaging  is  re- 
quired. Union  takes  place  more  rapidly  than  after  the  open 
operation. 


PUBIOTOMY 
The  Open  Method. — To  one  side  or  the  other  of  the  sj^mphysis, 


Fig.  33. — Pubiotomy,  open  method.  An  incision  is  made  over  the  os  pubis  into  which 
the  index  finger  of  the  left  hand  is  passed,  and  the  soft  parts,  especially  the  bladder  and 
urethra,  pushed  away  from  the  bone.  The  saw  carrier  is  then  passed  between  the  finger 
and  the  bone.      (From   Doderlein   and   Kronig.) 

the  left  being  preferred,  the  os  pubis  is  cut  down  upon  and 
laid  free  to  its  periosteum.  With  the  finger,  directed  posteri- 
orly, the  soft  parts  are  separated  from  the  bone,  a  Gigli  saw 
is  carried  around  the  os  pubis  at  a  point  midway  between  the 


INCREASING    THE   PELVIC    DIAMETERS 


99 


tubercles  of  the  os  pubis  and  the  origin  of  the  adductor  longus 
muscle,  and  the  bone  is  sawed  apart.     All  bleeding  arteries  are 


Fig.   34. — Pubiotomy,   open  method.      Fig.    33   shown   in   sagittal   section.      (From   Doderlein 

and   Kronig.) 


ligated  and  the  veins  clamped,  the  parts  temporarily  dressed,  and 
.an  elastic  binder  applied  around  the  hips.     After  delivery  the 


100 


THE    SURGICAL   PROCEDURES 


periosteum  is    sutured    together    Arith   catgut    aud    the    surface 
AYound  closed.     A  crescent-shaped  incision  with  its  base  at  the 


Fig.   35. — BumiTi"s    pubiotomy    needle. 


Fig.  36. — Pubiotomy,  subcutaneous  method.  The  needle  is  taken  in  tlie  right  hand 
and  passed  around  the  os  pubis,  the  fingers  of  the  left  hand  within  the  vagina  guiding 
its  point   close   to   the   bone.      (After   Bumm.) 

median  line  permits  more  freedom  to  the  subsequent  steps   of 
the  operation  than  a  straight  cut.     Drainage  is  not  necessary.    A 


INCREASING    THE    PELVIC    DIAMETERS 


101 


firm  binder  is  placed  about  the  pelvis  to  be  worn  for  several  days. 
(Figs.  33  and  34.) 

The  Closed  Operation — Bumm's  Method. — A  saw  carrier  (Fig. 
35)  grasped  firmly  in  the  right  hand  is  entered  between  the 
large  and  small  lips  of  the  vulva  at  a  point  opposite  the  clitoris. 
The  point  of  the  needle  is  directed  toward  the  lower  border  of 


Fig.   37. — Pubiotomy,    suljcutaneous    method.      This    is    Fig.    36    shown    in    sagittal    section. 
(From  Doderlein   and   Kronig.) 


the  pubic  bone,  and,  with  the  index  finger  of  the  left  hand  in 
the  vagina  as  a  guide,  the  needle  is  driven  around  the  pubes, 
coming  out  at  its  upper  posterior  border.  The  point  of  the 
needle,  showing  beneath  the  skin  of  the  mons  veneris,  is 
cut  down  upon  with  the  scalpel.  It  is  also  Avell  to  make  a  stab 
wound  with  the  point  of  the  scalpel  where  the  carrier  is  to  enter ; 


102 


THE   SURGICAL   PROCEDURES 


Fig.  38. — Subcutaneous  pubiotomy.  The  needle  has  been  passed  around  the  pubic 
bone  from_  below  upward;  and  a  Gigli  saw  attached  to  the  eye  of  the  needle  is  about  to 
be  drawn  intO'  position  for   sawing.      (After  Bumm.) 


INCREASING    THE   PELVIC    DIAMETERS 


103 


Fig.   39. — Subcutaneous    pubiotomy.      The    wire    saw    has    been    drawn    through,    and    the 
handles   affixed   ready    for   sawing   apart   the   pubic   bone.      (After   Bumm.) 


Fig.   40. — Doderlein   saw   carrier   and   saw. 


104  THE    SURGICAL   PROCEDURES 

otherwise  the  needle,  which  is  rather  blunt,  will  be  forced 
through  the  integument  with  considerable  difficulty  (Figs.  36 
and  37). 

To  the  protruding  end  of  the  needle  a  Gigli  saw  is  now  made 
fast  and  the  carrier  withdrawn,  bringing  the  saw  with  it  (Fig. 
38).  The  knees  are  held  together,  handles  affixed  to  the  ends  of 
the  saw,  and,  with  the  utmost  precaution,  the  bones  severed.  (Fig. 
39).  As  a  rule  there  is  not  much  hemorrhage;  and  what  there 
is,  is  easily  controlled ;  but  should  it  persist  in  spite  of  pressure, 
the  closed  wound  may  have  to  be  converted  into  an  open  one  and 
the  vessels  secured. 

The  woman  is  urged  to  deliver  herself  if  she  can;  but  must 
be  assisted  if  she  can  not.  Afterward  the  parts  receive  a  final 
inspection,  and  all  lacerations  are  repaired.  The  bladder  should 
be  catheterized,  and,  if  the  urine  is  bloody,  a  self -retaining  catheter 
should  be  left  in  for  twenty-four  to  thirty-six  hours.  The  pelvis 
should  be  supported  with  a  firm  bandage  at  least  a  few  days. 

Doderlein's  method  differs  from  the  foregoing  in  that  the  saw 
carrier  (Fig.  40)  is  passed  from  above  downward,  making  its 
exit  near  the  clitoris.  It  has  no  advantages.  The  shape  of  the 
Doderlein  pubiotomy  needle  is  like  that  of  a  Dechamp  ligature 
carrier,  only  it  is  much  larger. 

THE  PROGNOSIS 

In  228  symphyseotomies  performed  after  the  open  method, 
quoting  from  Hammerschlag,  the  maternal  mortality  was  8  per 
cent.  In  77  pubiotomies,  also  performed  after  the  open  method, 
the  mortality  was  10.5  per  cent.  Compared  with  the  subcuta- 
neous method:  in  17  cases  of  symphyseotomy  the  mortality  was 
6  per  cent;  in  700  pubiotomies  it  was  4.4  per  cent.  The  infant 
mortality  was  8  per  cent  in  the^  symphyseotomies  and  9  per.  cent 
in  the  pubiotomies,  regardless  of  method. 

As  regards  the  relative  safety  of  symphyseotomy  and  pu- 
biotomy there  is  little  difference;  but  in  both  the  mortality  is 
considerably  higher  by  the  open  than  by  the  closed  method. 
This  is  due  to  its  greater  liability  to  become  infected.  On  the 
other  hand,  the  injuries  are  more  hidden  when  done   subcuta- 


INCREASING    THE   PELVIC    DIAMETERS  105 

neoush',  as  it  is  sometimes  especially  difficult  to  control  bleeding; 
and  occasionally  a  death  has  resulted  therefrom. 

The  lacerations  accompanying  either  operation  may  be  nu- 
merous and  extensive.  Bladder,  urethra,  and  vagina,  to  some 
degree  suffer,  either  from  the  operation  itself  or  in  the  delivery 
which  follows;  and  all  such  lesions  are  likely  to  be  extended  if 
the  child  is  delivered  hurriedly  and  with  force.  Spontaneous 
birth,  therefore,  is  to  be  preferred,  and  ample  time  should  be 
given  the  tissues  to  dilate.     The  bladder  and  urethra  are  more 


Fig.   41. — The   pubiotomized   pelvis. 

likely  to  suffer  injury  in  the  symphyseotomy  than  in  the  pu- 
biotomy,  since  their  attachment  is  more  intimate  in  the  median 
line  than  laterally.  Owing  to  the  occult  character  of  such  in- 
juries, it  is  essential  after  every  such  operation  to  catheterize  the 
bladder  to  prove  the  presence  or  absence  of  blood  in  the  urine.  A 
severe  laceration  may  result  in  a  vesicovaginal  or  a  urethro- 
vaginal fistula,  which  later  will  require  surgical  correction. 
Many  of  the  lacerations  occur  in  the  vicinity  of  the  surgical 
wound,  and  enhance  the  dangers  of  infection  by  their  contiguity. 
One  may  obviate  tears  about  the  pubic  wound,  if  they  appear 


106  THE   SURGICAL   PROCEDURES 

imminent,  by  incising  the  vaginoperineal  wall  (episiotomy), 
thereby  relieving  the  tension  anteriorly. 

The  course  of  recovery  is  usually  without  morbidity.  The 
development  of  a  hematoma,  or  the  formation  of  a  thrombus  or, 
possibly,  an  embolus,  has  to  be  borne  in  mind.  Sometimes  a  hema- 
toma becomes  infected,  developing  an  abscess  that  requires 
evacuation  and  drainage.  If  there  be  good  reason  to  fear 
embolism,  the  patient  should  be  kept  in  bed  for  five  or  six  weeks. 

To  escape  just  condemnation  one  must  select  one's  cases  wisely, 
for  neither  symphyseotomy  nor  pubiotomy  has  a  very  broad  field 
of  usefulness,  and  should  be  undertaken  only  in  exceptional, 
well-studied  situations.  Their  limitations  must  be  known.  To 
misjudge  proportions;  to  separate  the  pelvis  when  the  fetal 
head  will  not  spontaneously  engage,  and  can  not  be  made  to 
engage ;  to  perform  the  operation  before  labor  has  been  thor- 
oughly tested,  must  all  fall  short  of  success.  Only  a  slightly 
increased  diameter  is  gained,  anyway,  and  this  mostly  in  the 
transverse  diameter.  And  after  the  pubes  have  been  separated, 
delivery  must  take  place  through  a  disorganized  canal  upon 
whose  integrity  normal  mechanism  so  much  depends. 

In  considering  the  sequels  of  the  operation,  three  things  are 
to  be  kept  in  mind, — the  nonunion  of  the  pelvis,  the  develop- 
ment of  hernia,  and  the  influence  the  operation  may  have  on  a 
subsequent  pregnancy. 

In  the  open  method  complete  recovery  may  take  two  or  three 
months.  If  infection  takes  place  in  the  symphysis,  the  joint  may 
never  flrmly  unite,  but  often  will  if  the  infection  occurs  in  the 
pubiotomized  bone.    Here  union  will  go  on  undisturbed. 

The  development  of  hernia  is  favored  by  pubiotomy  more  than 
by  symphyseotomy,  but  in  neither  is  it  very  likely  to  occur. 

What   effect   can   the    operation  have   on   subsequent   labors? 

For  one  thing  there  is  a  slight  but  permanent  increase  in  the 
diameter,  both  in  symphyseotomy  and  pubiotomy.  For  this 
reason  pubiotomy  has  been  performed  before  the  expiration  of 
pregnancy,  or  even  in  anticipation  of  pregnancy,  with  the  hope 
that  sufftcient  space  might  thereby  be  gained  to  make  spontaneous 
birth  possible.  If  pubiotomy  must  be  repeated,  it  is  recom- 
mended that  the  section  be  made  on  the  opposite  side. 


INCREASING    THE   PELVIC    DIAMETERS  107 

The  results  for  the  child,  in.  whose  interests  the  operation  is 
performed,  are  not  so  good  as  in  cesarean  section.  As  already- 
noted,  separating  the  pelvis  is  only  one  step  in  the  delivery.  All 
the  usual  casualties  of  birth  are  still  to  be  met.  These  are  con- 
siderably lessened  if  labor  goes  on  spontaneously,  but  take  on 
very  serious  aspects  when  further  obstetric  operations,  such  as 
the  application  of  forceps  or  version,  have  to  be  resorted  to. 

In  comparing  the  various  methods,  the  subcutaneous  introduc- 
tion of  the  wire  saw,  after  the  method  of  Bumm,  is  the  simplest 
and  quickest ;  the  partial  open  method  of  Doderlein,  though 
somewhat  more  complicated,  atfords  greater  protection  to  the 
bladder  and  urethra.  Each  procedure  possesses  advantages  that 
make  the  two  equally  serviceable. 

Symphyseotomy  and  pubiotomy  are  operations  to  be  recom- 
mended only  after  the  cervix  has  been  fully  dilated ;  after  active 
labor  has  been  given  a  fair  trial;  when  the  advancing  head  is  in 
partial  engagement  or  arrest ;  after  a  reasonable  attempt  to  de- 
liver vvdth  forceps ;  and  after  determining  that  the  child  is  alive. 
Even  then,  cesarean  section,  all  things  considered,  is  probabl.y 
the  better  operation. 


CHAPTER  VI 

THE  CORRECTIOX  AXD  TREATMENT  OF  FAULTY 
ATTITUDES  AXD  PROLAPSED  PARTS 

The  normal  attitude  of  the  fetus  is  one  of  flexion.  The  body 
lies  bent  upon  itself,  the  chin  pressed  against  the  breast,  and  the 
extremities  folded  over  the  chest  and  abdomen.  The  concavity 
thus  formed  siiiTounds  and  protects  the  placenta  and  cord. 
Derangement  of  this  most  favorable  adaptation  of  embryo  and 
placenta  is  accompanied  by  various  and,  sometimes,  serious  con- 
sequences. Change  this  attitude  of  flexion  to  one  of  extension, 
and  the  fetal  ovoid  becomes  distorted,  the  extremities  "wander, 
the  cord  slips  out  of  place — all  being  variations  from  the  normal 
vhich  become  more  or  less  serious  for  both  mother  and  child. 

Conversion  of  Face  and  Brow  Positions. — Presentation  by  the 
face  generally  comes  about  from  a  veak  labor  and  a  contracted 
pelvis,  and  engagement  is  delayed  and  extension  favored.  If 
observed  early,  the  face  may  be  converted  into  a  vertex  after 
the  following  method: 

One  hand  (the  right  in  left,  the  left  in  right,  positions)  is 
passed  along  the  face,  brow,  and  top  of  the  head  to  the  occiput, 
w^hich  is  grasped  securely  and  drawn  downward.  At  the  same 
time  the  outside  hand  is  pressed  against  the  bowed  thorax  of  the 
fetus  while  an  assistant  makes  counterpressure  on  the  breech 
(Fig.  43).  Baudelocque  considered  the  single  hand  within  the 
uterus  quite  sufficient  to  effect  the  conversion,  and  Schatz  was 
able  to  correct  the  displacement  by  external  manipulations  alone; 
but  the  combined  method,  undoubtedly,  is  best,  especially  in  the 
more  marked  degrees  of  extension.  The  success  of  the  operation 
presupposes  that  both  mother  and  child  are  in  good  condition, 
that  the  soft  parts  are  dilated  or  easily  dilatable,  and  that  the 
head  is  movable.     After  correcting  the  attitude,  labor  may  be 

108 


FAULTY    ATTITUDES    AND    PROLAPSED   PARTS 


109 


expected  to  go  on  normally  and  end  spontaneously,  though  it 
must  be  borne  in  mind  that  the  manipulations  can  induce  asphyxia 
of  the  child,  and  make  rapid  delivery  imperative.  In  getting 
past  the  head  with  the  hand,  and  especially  in  reducing  the  mal- 
position, there  must  be  a  certain  amount  of  mobility  and  relaxa- 
tion of  the  parts.     The  following  contraindications  to  the  pro- 


Fig.   42.- — Vertex    presentation   in    the    oblique    diameter.      Tlie    amnion    is    still    intact,    and 
must   be    ruptured    before   applying   forceps.      (After   a   frozen   section    by    Braune.) 


cedure  have  value :  a  contracted  pelvis,  prolapse  of  an  extremity, 
low  implantation  of  the  placenta,  and  a  prolapse  of  the  cord. 

After  flexion  has  been  secured,  the  patient  is  turned  on  the 
side  corresponding  to  the  back  of  the  child,  the  occiput  lying 
within  the  pelvis  or  at  least  engaged  at  the  brim.  Since  such 
manipulations  always  augment  the  possibilities  of  asphyxia,  the 
fetal  heart  should  be  listened  to  at  frequent  intervals. 

Closely  associated  Avith  the  face  position  is  that  of  the  brow. 


110 


THE    SURGICAL   PROCEDURES 


Fig.  43. — Thorn's  manipulation.  The  attempt  is  made  to  bring  down  the  occiput  with 
one  hand  while  with  the  other  pressure  is  made  against  the  child's  thorax  from  the  out 
side.     At  the  same  time  an  assistant  makes  pressure  in  an  opposite  direction  on  the  breech. 


FAULTY   ATTITUDES   AND   PROLAPSED   PARTS  111 

In  the  milder  degrees  of  extension,  version  may  be  indicated,  or 
possibly  the  brow  converted  into  a  vertex.  Failing  in  this,  it  may 
be  brought  into  a  frank  face  by  hooking  the  fingers  into  the 
child's  month  and  drawing  the  chin  down.  The  following  case 
illustrates  how  such  an  anomaly  may  be  managed: 

Thirteenth  labor.  Fiist  position  of  the  brow,  head  remaining  well  above 
the  symphysis.  Contraction  ring  so  tight  about  the  neck  that  the  introduced 
hand  could  not  pass  beyond  it.  Attempt  to  turn  abandoned;  instead,  its  con- 
version into  an  occipitoijosterior  position  was  undertaken.  With  the  left  hand 
the  brow  was  pushed  upward  and  to  the  right,  the  external  hand  simultaneously 
making  pressure  downward  on  the  occiput.  An  assistant  meanwhile  urged  the 
breech  toward  the  left.  The  maneuver  was'  successful,  and  a  spontaneous  birth 
of  a  living  child  followed. 

Reposition  of  an  Extremity. — AVhen  the  posture  of  the  fetal 
ovoid  is  such  that  the  uterine  wall  does  not  embrace  it  snugly, 
a  fetal  extremity  may  become  dislodged,  and  find  its  way  along- 
side or  in  front  of  the  advancing  part.  In  a  cross-birth,  for 
example,  the  contracting  ring  of  the  uterus  can  not  with  uni- 
formity adjust  itself  about  the  child's  shoulders,  so  that  a  hand 
or  a  foot  easily  becomes  displaced  along  the  path  of  least  resist- 
ance. (Fig.  44.)  In  breech  positions,  too,  the  irregularity  of  the 
buttocks  prevents  uniformity  of  pressure,  and  prolapse  of  one 
or  both  feet  may  result.  Nor  Avould  it  help  matters  to  replace 
the  extremity,  because  there  is  nothing  to  keep  it  from  recurring. 

In  vertex  positions  it  is  different.  Owing  to  the  spherical 
form  of  the  child's  head  and  its  more  perfect  adjustment  to  the 
contracting  ring,  it  is  unusual  for  an  extremity  to  become  dis- 
placed. It  does,  however,  occur  with  relative  frequency  in  face 
positions  and  in  pelvic  deformities,  also  in  hydramnion,  and 
where  the  use  of  the  metreurynter  has  caused  displacement  of 
the  head.  When  the  head,  which  is  seldom  a  factor  in  the  de- 
velopment of  anomalous  attitudes  of  the  fetus,  allows  an  ex- 
tremity to  slip  past  it  (Fig.  45),  postural  treatment  will  gen- 
erally correct  the  displacement  if  the  amniotic  sac  is  still  intact, 
as  demonstrated  by  the  following  instance: 

A  tripara.  Normal  pelvis.  Fetus  in,  left  vertex  position,  with  the  head 
deviated  to  the  left.  Sac  unruptured;  cervix  partially  dilated.  Through  the 
membranes  could  be  felt  the  left  forearm  and  hand  lying  near  the  head.     Tlie 


112 


THE    SURGICAL    PROCEDURES 


patient  \Yas  turned  on  her  left  side.  After  two  hours  the  sac  ruptured  and 
the  head  became  engaged.  Birth  ended  spontaneously.  The  compound  pre- 
sentation probably  would  have  persisted,  had  the  patient  assumed  the  right 
lateral  or  upright  j)Osture. 


Fig.   44. — Prolapse    of    a    hand    and    foot    in    transverse    position.       (The    original    drawing 

is   by    Van   Rymsdyke.) 


If  the  arm  lies  in  marked  extension,  and  attempts  to  replace 
it  fail,  the  accoucheur  should  wait  until  the  cervix  is  fully  dilated 
before  again  undertaking  its  reposition.     The  complicating  mem- 


FAULTY    ATTITUDES    AND   PROLAPSED   PARTS 


113 


ber  is  then  pushed  up  past  the  head,  the  sac  ruptured  artificially, 
and  the  head  pressed  from  above  into  the  superior  strait.     As 


Fig.   45. — Prolapse    of    an    arm,    left    occipitoposterior    position.       (Bumm.) 


the  water  drains  away,  the  head  becomes  fixed,  and  recurrence 
of  the  displacement  is  prevented.     To  carry  out  this  maneuver 


114  THE    SURGICAL   PROCEDURES 

the  patient  must  be  in  a  favorable  position  for  operation  and  be 
anesthetized.  The  whole  hand  is  passed  into  the  vagina  (in  left 
positions,  the  right  hand;  in  right  positions,  the  left  hand),  and 
the  prolapsed  member  is  grasped  and  pushed  up  over  the  face 
beyond  the  chin.  AYith  the  external  hand  the  head  is  now 
pressed  into  the  pelvic  opening  and  held  until  anesthesia  passes 
oif  and  the  contractions  of  the  uterus  secure  the  head  at  the 
inlet.  Labor  is  allowed  to  progress  with  the  patient  lying  on 
the  side  to  which  the  fetal  back  is  turned. 

With  the  expectation  that  spontaneous  delivery  Avill  follow, 
reposition  of  the  prolapsed  extreinity  is  undertaken  only  when 
there  are  no  indications  for  rapid  delivery  and  no  undue  obstruc- 
tion. If  the  head  alongside  the  prolapsed  arm  enters  the  pelvis, 
the  treatment  is  expectant,  since  birth  will  go  on  spontaneously 
in  spite  of  the  anomaly.  Small  fetuses  are  not  rarely  born  in 
this  way.  Should  rapid  delivery  be  indicated,  the  forceps  is 
employed,  care  being  taken  not  to  include  the  prolapsed  part  in 
its  grasp.     If  the  child  is  dead,  perforation  has  its  place. 

It  may  sometimes  happen  in  undeveloped  or  macerated  fetuses 
that  a  lower  extremity,  instead  of  an  arm  will  come  down.  The 
management  is  the  same,  the  extremity  replaced  and  the  patient 
put  on  the  side.  If  reposition  be  impossible,  or  should  both  a 
foot  and  an  arm  present,  it  would  be  best  to  pull  the  leg  down 
and  push  the  arm  up,  that  is,  convert  it  into  a  breech.  Even 
then  an  arm  will  sometimes  persist  in  prolapsing ;  but  no  treat- 
ment is  needed,  as  the  condition  will  take  care  of  itself. 

Re'position  of  the  Cord. — The  best  way  to  deal  with  this 
anomaly  is  through  immediate  delivery,  but  this  is  only  prae-. 
ticable  if  the  soft  parts  are  well  dilated  and  relaxed.  Should 
compression  occur  at  a  time  when  labor  can  not  be  rapidly  com- 
pleted, reposition  may  be  etfected  and  the  danger  obviated. 

Since  compression  of  the  cord  is  of  importance  only  as  it  en- 
dangers the  life  of  the  child,  it  calls  for  no  consideration  if  the 
child  is  dead  or  nonviable.  Success  through  immediate  delivery 
is  gauged  by  the  clock.  A  few  minutes  of  interrupted  circulation, 
and  the  child  is  lost.  And,  as  the  head  is  the  only  part  of  the 
fetus  that  is  able  to  prevent  the  reposed  cord  from  again  falling, 
its  reposition  in  any  other  position  is  practically  useless,  though 


FAULTY   ATTITUDES   AND   PROLAPSED   PARTS  115 

sometimes,  if  one  has  it  ready  at  hand,  a  metreurynter  may  be 
used  in  lien  of  the  head  to  keep  the  cord  out  of  the  way  of  harm 
until  full  dilatation  makes  rapid  extraction  possible.  Occasion- 
ally, one  may  succeed  in  hanging  the  cord  over  one  of  the  fetal 
extremities.     The  method  of  procedure  is  as  follows: 

Patient  and  surgeon  undergo  the  usual  disinfection.  The  vag- 
inal douche  may  be  omitted  altogether,  or,  if  given,  must  be  given 
cautiously,  as  the  manipulations  within  the  vagina  may  cause 
harmful  pressure  on  the  cord.  Narcosis  is  essential  to  success. 
Without  it  the  patient  is  likely  to  resist,  especially  when  the 
hand  is  introduced  into  the  vagina.  Anesthesia  also  modifies 
the  force  of  the  uterine  contractions,  which,  for  a  few  moments, 
is  desirable. 

The  patient  is  brought  to  the  edge  of  the  bed,  lying  on  the 
back,  thighs  flexed,  knees  everted.  An  operating  table  when  ac- 
cessible is  always  to  be  preferred.  The  hips  should  be  elevated 
a  little  higher  than  the  head,  a  position  favoring  reposition  by 
gravity.  This  is  easily  secured  by  placing  one  or  more  pillows 
under  the  buttocks  as  the  patient  lies  crosswise  on  the  bed. 

The  left  hand  is  introduced  in  left  positions  of  the  fetus,  the 
right  in  right  positions.  The  cord  is  grasped  with  as  many 
fingers  as  the  opening  in  the  uterus  will  admit,  and  passed  over 
the  child's  face  and  planted  as  high  up  as  possible.  Before 
withdrawing  the  fingers,  it  is  well  to  stimulate  a  contraction  by 
rubbing  the  uterus  with  the  other  hand.  As  the  contraction 
comes  on,  the  head  is  grasped  externally  and  pressed  downward 
as  the  fingers  are  withdrawn,  the  object  being  to  keep  the  cord 
above  the  engaging  head.  If  the  reposition  has  been  successful, 
and  the  head  lies  fixed  in  the  lower  segment  of  the  uterus,  the 
patient  is  returned  to  bed,  and  labor  is  allowed  to  go  on  natu- 
rally. Should  the  cord  again  slip  out  of  place,  the  procedure  is 
repeated,  preferably  with  the  patient  in  the  knee-chest  position. 
This  posture  produces  a  negative  pressure  within  the  uterus  that 
makes  reposition  easier;  but  narcosis  is  not  so  conveniently  se- 
cured, and  may  have  to  be  omitted. 

A  point  worth  remembering  is,  that  light  pressure  on  the 
cord  continued  for  a  long  time  is  more  dangerous  than  firm  pres- 
sure applied  for  a  short  time.    Hence  one  should  operate  boldly 


116  THE    SURGICAL    PROCEDURES 

and  rapidly  rather  than  timidly  and  slowly.  After  replacing  the 
cord  with  the  patient  in  the  knee-chest  posture,  she  should  be 
Ijut  on  the  side  to  which  the  child's  back  is  turned. 

As  soon  as  reposition  has  been  effected,  the  fetal  heart  becomes 
slower,  but  rapidly  returns  to  normal  after  pressure  is  relieved. 
Until  labor  has  progressed  beyond  the  possibility  of  recurrence, 
the  fetal  heart  sounds  should  be  listened  to  at  frequent  intervals. 

In  rare  instances  the  cord  may  prolapse  in  head  presentations 
while  the  amniotic  sac  is  still  unruptured  and  the  os  undilated. 
Posture  alone  will  oftentimes  correct  the  displacement;  but  if 
it  does  not,  it  must  be  treated  as  above  described.  The  sac  need 
not  necessarily  be  ruptured  in  order  to  do  it. 

In  cross-births  and  breech-births  complicated  with  prolapse 
the  metreurynter  becomes  serviceable.  Before  placing  it  in  posi- 
tion, the  cord  must  first  be  pushed  high  up  and,  when  possible, 
looped  over  an  extremiity;  otherwise  it  may  become  compressed 
between  the  metreurynter  and  the  advancing  part. 


CHAPTER  VII 
VERSION 

Version  implies  a  cliange  of  position,  not  merely  a  change  of 
presentation.  To  convert  a  head  presentation  into  one  of  the 
breech,  or  a  cross-birth  into  one  of  the  head,  is  version;  but  to 
alter  a  breech  presentation  by  making  it  one  of  the  foot,  is  not 
version,  for  the  poles  of  the  child  remain  unchanged. 

There  are  two  general  indications  for  version:  (1)  as  a  measure 
of  expediency  in  rapid  delivery;  and,  (2)  as  a  maneuver  whereby 
the  relations  of  the  fetus  to  the  pelvic  inlet  may  be  so  adjusted  as 
to  make  birth  easier  or,  at  least,  possible. 

An  indication  for  rapid  delivery  arises,  for  example,  in  a  mild 
type  of  placenta  previa  when  the  head  of  the  child  lies  so  high 
that  forceps  can  not  be  applied.  By  turning  the  fetus,  a  foot  may 
be  grasped  and  the  child  extracted.  The  cross-birth,  the  occipito- 
posterior  position,  and  the  brow-presentation  are  other  conditions 
which  may  deliberately  be  so  turned  that  birth,  instead  of  being 
dangerous  or  impossible,  becomes  comparatively  easy  and  safe. 

Version  may  be  undertaken  to  bring  down  the  head  (cephalic 
version)  or,  to  bring  down  the  breech  (poclalic  version);  and  there 
are  three  ways  of  doing  it:  (1)  by  external  manipulations  alone, 
(2)  by  intei-nal  alone,  and  (3)  by  a  combination  of  the  two. 

External  Version  by  the  Head. — The  conversion  of  a  transverse 
or  a  breech  presentation  into  one  of  the  head  is  undertaken 
through  the  abdominal  wall.  The  operation  is  practically  clanger- 
less  for  either  the  mother  or  the  child.  By  it  one  is  able  to  secure 
a  vertex  presentation  in  place  of  some  other  and  less  favorable 
presentation.  Besides,  the  vertex  once  fixed,  birth  goes  on  more 
advantageously  than  it  otherwise  can. 

An  exact  diagnosis  having  previously  been  made,  the  patient 
is  placed  lengthAvise  on  the  bed,  and  the  operator  seats  himself 
beside  her.     One  hand  is  laid  on  the  head  of  the  fetus,  the  other 

117 


118 


THE    SURGICAL   PROCEDURES 


on  the  iDreech,  and  pressure  is  made  in  opposite  directions,  just 
as  one  turns  the  steering  wheel  of  an  automobile,  if  such  a  com- 
parison be  permissible.  The  force  applied  may  be  continuous 
or  intermittent,  so  long  as  each  gain  is  held.  The  turning  is 
continued  until  the  head  occupies  the  middle  line  over  the  pelvif* 
inlet.     (Fig.  46.)     With  sensitive  women  or  Avith  those  who  have 


Fig.   46. — External  version. 


thick,  resisting  abdominal  walls,  it  is  better  to  operate  under 
anesthesia.  Even  then  it  is  not  always  possible  to  effect  the 
change.  If  the  amount  of  amniotic  fluid  is  greatly  diminished, 
attempts  at  version  only  distort  the  uterus  and  its  contents;  and 
on  the  other  hand,  an  excessive  amount  of  fluid  prevents  one 
from  grasping  the  child  securely.  A  very  large  child  and  a 
very  small   child  present  the   same   troubles ;    they    make    the 


VERSION  119 

manipulations  difficult.  Obviously,  the  fetus  must  be  movable 
or  it  can  not  be  turned. 

After  the  direction  of  the  poles  of  the  child  has  been  re- 
versed, the  object  is  to  keep  the  head  fixed.  This  is  favored  by 
rupturing  the  sac,  thereby  allowing  the  uterus  to  contract  about 
the  child.  The  rupture  should  be  done  in  a  way  that  will  allow 
Ihe  fluid  to  escape  gradually.  If  it  comes  with  a  gush  there  is 
danger  of  the  cord  being  carried  out  with  the  sudden  flow. 

While  the  mouth  of  the  uterus  is  still  closed,  the  sac  should 
not  be  ruptured,  but  the  head  should  be  held  in  position  by 
mechanical  means,  which  is  done  by  placing  pads  at  the  sides  of 
the  head  and  holding  them  there  with  a  bandage  tightly  applied 
about  the  mother's  body.  Afterward  the  patient  is  put  on  her 
back  in  bed,  and  kept  quiet. 

A  case  comes  to  mind  of  a  woman  who  on  four  occasions  had  a 
transverse  presentation  of  the  child.  Internal  version  was  per- 
formed twice,  and  the  combined  version  once  with  fatal  results 
to  the  child  each  time.  In  the  last  month  of  the  fourth  preg- 
nancy, twenty  days  before  labor,  the  child  was  turned  by  ex- 
ternal manipulation,  the  head  fixed  by  bandaging,  and  the  patient 
kept  in  bed.    Spontaneous  birth  and  a  live  child  was  the  outcome. 

The  situation  which  most  frequently  makes  external  version 
by  the  head  feasible  is  a  transverse  presentation  of  the  second 
twin  in  a  dual  pregnane}^,  since  therein  are  fulfilled  all  the  pre- 
liminary conditions  enumerated. 

External  Version  by  the  Breech, — Turning  the  child  from 
some  other  presentation  to  one  of  the  breech  is  seldom  done, 
and  rarely  by  external  manipulation  alone ;  not  because  the 
operation  is  cliificult  to  do,  but  because  it  is  not  often  considered 
expedient.  The  same  principles  apply  to  its  performance  as 
Avere  enumerated  under  external  version  by  the  head.  Whether 
a  transverse  presentation  shall  be  converted  into  one  of  the 
head  or  into  one  of  the  breech  depends  largely  on  which  pole  of 
the  fetus  lies  nearer  the  pelvic  inlet.  Another  reason  for  chang- 
ing a  vertex  or  a  transverse  presentation  into  one  of  the  breech 
is,  that  it  offers  the  operator  a  better  hold  for  delivery.  For  ex- 
ample, in  placenta  previa,  before  the  sac  has  ruptured,  external 


120  THE    SURGICAL   PROCEDURES 

version  by  the  breecli  may  be  effected,  and  later  a  foot  grasped 
without  doing'  the  parts  great  violence. 

Internal  Version. — Although  the  internal  hand  has  the  more 
difficult  part  of  the  operation  to  perform,  the  external  hand 
coordinates  with  it  in  a  very  effectual  way  by  offering  support 
and  counterpressure  to  the  fetal  ovoid,  so  that  internal  version 
is  really  a  bimanual  procedure. 

Internal  version  is  indicated  in  the  following  conditions:  (1) 
when  the  head  of  the  child  will  not  engage,  (2)  in  transverse 
presentations,  and  (3)  in  certain  presentations  of  the  head. 

In  case  the  head  of  the  child  will  not  engage  in  the  presence 
of  active  labor,  assuming  that  no  marked  inequality  exists  be- 
tween the  child  and  the  mother,  podalic  version  has  advantages. 
Compared  with  the  high  forceps  operation  it  is  the  safer  of  the 
tAvo.    Its  advantages  will  be  referred  to  later. 

Cross-births  left  to  nature  are  accompanied  by  serious  conse- 
quences, to  both  mother  and  child.  Either  the  fetus  must  be 
abnormally  small  or  the  mother  abnormally  large  for  spontaneous 
birth  to  occur.  For  this  reason  the  baby  must  be  turned,  and, 
as  stated  above,  version  into  a  vertex  is  the  freest  from  danger. 
But  in  the  majority  of  cases  this  is  not  readily  accomplished, 
since  the  preliminary  conditions  that  afford  sufficient  mobility 
are  wanting.  The  introduced  hand,  can  do  little  with  the  head, 
but  the  leg  and  foot  provide  excellent  members  upon  which  to 
make  traction.  If  one  sees  the  patient  early  enough,  external 
version  would  be  the  operation  of  choice ;  but  the  physician  is 
often  brought  to  the  patient  after  labor  has  been  in  progress 
for  hours,  and  the  amniotic  sac  long  since  ruptured. 

Arrest  of  the  head  at  the  isthmus  of  the  pelvis,  as  in  brow 
and  occipitoposterior  positions,  may  be  successfully  treated  by 
version.  Even  when  the  vertex  presents  in  an  anterior  position, 
it  is  sometimes  desirable  to  reverse  the  poles  of  the  fetus,  as 
noted  in  prolapse  of  the  cord,  placenta  previa,  and  moderate 
degrees  of  pelvic  contraction. 

The  preliminary  conditions  upon  which  the  success  of  internal 
version  depends  are,  (1)  the  mouth  of  the  uterus  must  be  fully 
dilated;  (2)  the  advancing  head  of  the  child  must  not  be  fixed 
in  the  pelvis;  (3)  the  child  must  be  movable;  and  (4)  absolute 
contractions  of  the  pelvis  must  not  be  present. 


VERSION  121 

The  cervix  must  be  fully  dilated  for  the  reason  that  the  entire 
hand  of  the  operator  has  to  be  passed  into  the  uterus.  The 
obstetrician  should  make  sure  of  this,  for  he  can  easily  be  mis- 
led into  believing  the  whole  cervix  is  open  when  really  it  is  only 
the  external  os  that  is  dilated.  One  should  satisfy  himself  on 
this  point  by  sweeping*  the  fingers  around  the  head  of  the  child 
as  it  lies  within  the  uterus ;  nor  should  one  forget  that  abnormal 
irritation  of  the  uterus  through  prolonged  and  ineffectual  at- 
tempts at  delivery  can  cause  a  partial  closure  of  the  internal 
OS,  sometimes  spoken  of  as  a  stricture,  which  will  offer  for  the 
time  being  an  insurmountable  bar  to  delivery. 

In  order  to  get  hold  of  the  foot,  the  child's  head  must  be  free 
in  the  pelvis.  If  it  is  fast,  the  operator's  hand  can  not  be  passed 
beyond  it.  However,  one  is  justified  in  making  use  of  the  relax- 
ing effect  of  narcosis  before  abandoning  the  attempt.  The  body 
of  the  child,  too,  must  be  movable.  If  the  lower  segment  of  the 
uterus  is  much  thinned  out,  there  is  danger  of  rupturing  it  with 
the  hand;  and  this  clanger  is  greatly  increased  by  the  added 
strain  of  version,  especially  if  the  uterus  is  in  a  tonic  state  of 
contraction.  Such  a  condition  makes  the  operation  practically 
impossible. 

Failure  to  turn,  calls  for  other  procedures,  such  as  the  use  of 
forceps,  pubiotomy,  or  even  craniotomy;  and  to  attempt  version 
in  the  presence  of  absolute  pelvic  contraction  would  be  worse 
than  useless.     Such  cases  demand  cesarean  section. 

Edema,  scar  tissue,  neoplasms,  and  congenital  malformations 
play  the  same  part  externally  that  the  bony  parts  play  inter- 
nally, and  by  their  presence  contraindicate  version. 

The  Technic  of  Internal  Version. — Narcosis  is  of  special  service 
in  the  performance  of  internal  version.  To  pass  the  hand  and 
arm  into  the  birth  canal  excites  uterine  activity,  which  increases 
in  intensity  as  the  cavity  becomes  penetrated.  Narcosis  does 
aAvay  with  much  of  this  reflex  excitability.  Version  may  be 
undertaken  in  favorable  cases  without  it  if,  for  any  good  reason, 
anesthesia  is  contraindicated.  But,  since  one  never  can  tell 
exactly  how  difficult  a  given  case  is  going  to  be,  it  is  wise  to 


122  THE    SURGICAL   PROCEDURES 

follow  the  general  rule  of  putting  the  patient  to  sleep  before 
beginning  the  operation. 

Lying  crosswise  on  the  bed,  or,  better  still,  lying  on  the  operat- 
ing table,  the  knees  separated  and  supported,  is  the  preferable 
position  for  internal  version.  In  this  posture  disinfection  is 
more  readily  applied  and  more  surely  maintained.  There  may  be 
conditions,  as  in  marked  pendulosity  of  the  abdomen,  when  it 
will  be  found  helpful  to  turn  the  patient  on  her  side.  If  it  is 
desired  to  change  from  the  dorsal  to  the  lateral  position  in  the 
midst  of  the  operation,  the  leg  of  the  patient  may  be  carried  over 
the  head  of  the  operator  without  the  necessity  of  withdrawing 
his  hand. 

The  operator  kneels  in  front  of  the  bed,  and  the  appropriate 
hand  is  passed  into  the  cavity  of  the  uterus.  Since  the  foot  of 
the  child  is  the  object  sought,  that  hand  is  employed  Avhich  will 
more  readily  reach  and  grasp  it.  If  the  feet  of  the  child  lie  at  the 
mother's  left  side,  the  right  hand  of  the  operator  is  introduced; 
if  to  the  mother's  right,  his  left  hand  is  used.  Should  the  mis- 
take of  passing  the  wrong  hand  be  made,  it  is  not  serious,  and 
need  not  be  corrected  unless  it  is  found  impossible  to  effect  ver- 
sion with  the  one  already  in  the  uterus. 

In  passing  the  hand  into  the  birth  tract,  the  ends  of  the  fin^ 
gers  are  brought  together  and  introduced  slowly  and  cau- 
tiously while  with  the  other  hand  the  labia  are  separated. 
(Figs.  47  and  48.)  If  the  sac  is  already  ruptured  the  fluid  may 
furnish  sufficient  lubrication;  otherwise  the  gloved  hand  should 
be  made  slippery  with  lysol  solution.  The  operation  sel- 
dom requires  haste  in  its  performance.  Even  in  deep  narcosis 
the  entering  hand  will  stimulate  contractions  of  the  uterine  and 
abdominal  muscles,  which  must  be  overcome  gradually  and  be- 
tween pains;  the  sac  is  ruptured,  the  advancing  part  pressed  to 
one  side,  and  the  hand  pushed  on  into  the  cavity  of  the  amnion. 
As  soon  as  the  internal  hand  has  passed  the  vulva  the 
other  is  placed  on  the  abdomen,  the  spread  fingers  spanning 
the  fundus  of  the  uterus.  By  supporting  the  organ  in  this  Avay 
the  danger  of  loosening  the  uterovaginal  attachment  with  the 
internal  hand  is  greatly  lessened.     (Figs.  49  and  50.) 


VERSION 


123 


Fig.   47. — Gloved  hand   shaped   for  introduction  into  the   birth  canal. 


Fig.  48. — \'ersion  in  the  second  [position  of  the  verte.x.  First  step.  The  fingers  and 
thumb  of  the  right  hand  are  brought  together  in  the  shape  of  a  cone;  the  fingers  of 
the   other  hand  hold  the  labia  apart. 


124 


THE    SURGICAL   PROCEDURES 


The  next  maneuver,  that  of  getting  hold  of  a  foot,  is  some- 
times troublesome  because  of  the  difficulty  in  determining  the 
true  relations.  The  face  is  easily  made  out  by  touch,  but  not 
the  feet,  for  they  occupy  a  much  more  contracted  space.  In  the 
vertex  position  the  feet  commonly  lie  above  in  the  fundus  of  the 
uterus,  although  occasionally  they  may  be  found  near  the  head. 


Pig.   49. — Version    in    the    second    position    of    the    verteoc.      Second    step.      Searching    for 
the  feet  with  the  right  hand,  the  left  hand  pressing  upon  the  fundus  externally. 


In  the  transverse  presentations,  dorsum  posterior,  they  gen- 
erally lie  crossed  on  the  abdomen  of  the  child  in  front,  but 
they  may  become  extended. 

In  order  to  reach  the  feet  the  hand  is  slipped  along  the  border 
of  the  thorax  and  to  the  thigh  and  leg.  Or  one  may,  if  the  diag- 
nosis of  position  has  been  carefully  made,  proceed  by  the  shorter 


VERSION" 


125 


route,  going  directly  to  the  feet  over  the  face  and  belly  of  the 
fetus.  One  method  is  known  as  the  indirect  or  French,  the  other 
as  the  direct  or  German.     Each  has  its  advantages   (Fig.   51). 


Fig.  50. — Version  in  the  second  position  of  the  vertex.  The  entire  right  hand  is 
passed  into  the  uterus  to  the  fundus  in  search  of  a  foot,  the  outer  hand  making  pres- 
sure  over  the   region  of   the   child's  buttock. 


By  the  French  method  the  hand  is  carried  to  the  foot  Avith  greater 
certainty,  obviating  the  mistake  of  grasping  a  hand  instead  of  a 


126 


THE    SURGICAL    PROCEDURES 


foot ;  and  in  certain  cases  it  is  to  be  preferred.  But,  inasmuch  as 
it  requires  a  wider  excursion  of  the  hand  within  the  uterus,  it  is 
not  always  possible  of  execution. 


Fig.  51. — \'ersion  in  the  Second  Position  of  the  Vertex.  The  inner  (right)  hand  has 
grasped  and  drawn  down  the  anterior  foot;  the  external  hand  is  applied  to  the  fundus 
of  the   uterus.      (Hammerschlag.) 

In  considering  which  foot  shall  he  brought  doA\'n,  the  following 
rule   should   be  followed:    Choose   that   foot   which   will,   when 


VERSION 


127 


Fig.  52. — Version  in  the  first  dorsoanterior  transverse  position:  the  arm  prolapsed. 
The  introduced  (left)  hand  has  grasped  and  drawn  down  the  lower  foot  while  the  ex- 
ternal hand  presses  on  the  child's  buttock.  An  assistant  makes  traction  by  means  of  a 
sling  applied  to  the  child's  wrist. 


128 


THE    SURGICAL    PROCEDURES 


clraAvn  ujDon,   favor  the  preservation   of  or  the   rotation  to   an 
anterior  position  of  the  occiput. 

To  secure  this  advantage  the  anterior  foot  in  all  vertex  presen- 
tations is  chosen.     In  transverse  presentations,  with  the  back  of 


Fig.   53. — Version  in   the  second  dorsoposterior   transverse   position.      The  internal    (right) 
hand   grasps   the   upper  foot;   the   external   hand   is  pressed   upon  the  child's  buttocks. 

the  child  lying  toward  the  mother's  abdomen,  it  is  the  posterior 
foot;  with  the  back  toward  the  mother's  back,  it  is  the  anterior 
foot.  (Figs.  51,  52  and  53.)  One  is  sometimes  content  to  take  the 
first  one  that  can  be  reached,  whether  it  be  the  more  favorable  or 
not.    An  extremity  should  never  be  pulled  down,  however,  before 


VERSION 


129 


fully  determining  which  member  it  is.  Presuming  it  to  be  a 
foot,  one  proceeds  to  prove  it  by  its  characteristic  landmarks. 
To  tell  an  arm  from  a  leg  is  not  always  easy,  but  the  foot  ought 
to  be  readily  identified  by  its  short  toes,  the  ankle,  and  the  heel. 

All  activity  should  cease  during  a  contraction. 

When  reached,  the  foot  is  grasped  (Fig.  53)  between  the 
operator's  second  and  third  fingers  and  held  fast.     It  may  be 


Fig.   54. — Version   in   the   second   position   of   the   vertex.      Third   step.      A   foot   is   grasped 
and  drawn  down  to  the  introitus,  the  external  hand  pushing  upward  on  the  child's  head. 


pulled  down  into  the  vagina  without  changing  the  position  of 
the  child,  whose  actual  turning  does  not  begin  until  this  poi]it 
is  reached. 

As  the  operator  continues  to  draw  slowly  and  carefullj^  on 
the  extremity  with  the  one  hand,  he  presses  upward  with  the 
other.     (Figs.  54  and  55.) 


130 


THE    SURGICAL    PROCEDURES 


Not  until  the  knee  is  visible  at  tlie  vulva  is  one  sure  that 
version  has  been  accomplished.     (Fig.  56.) 

Combined  Vetsion. — The  combined  version  diifers  from  inter- 
nal version  in  that  the  outer,  instead  of  the  inner,  hand  performs 


Pig.   55. — Version   in   the   second   position   of   the  vertex.      Inner  view   of  Fig.    54. 

the  more  important  part.  "Without  their  cooperation,  however, 
turning  could  not  be  effected;  and  since  only  tAvo  fingers  are 
used  in  the  uterus,  the  operation  is  employed  only  in  the  earlier 
stages  of  labor,  before  dilation  has  taken  place. 


VERSION 


131 


The  indications,  briefly  stated,  are  (1)  in  placenta  previa 
partialis;  (2)  in  transverse  presentations  with  premature  rupture 
of  the  amnion;  (3)  in  prolapse  of  the  umbilical  cord  in  vertex 
presentations,  the  os  uteri  undilated;  and  (4)  in  dangers  threaten- 
ing the  life  of  the  mother  in  the  first  stage  of  labor. 


Fig.  56. — Version  in  the  second  transverse  position.  Fourth  step.  The  foot  and  the 
leg  as  high  as  the  knee  have  been  brought  outside  the  vulva.  The  head  is  now  in  the 
fundus,    and   version   is   complete. 


The  usual  disinfection  of  the  operator  and  patient  is  observed. 
Few  instruments  are  needed.  A  tenaculum  forceps,  a  dressing  for- 
ceps or  other  instrument  suitable  for  rupturing  the  sac,  a  placental 
forceps  with  which,  under  certain  circumstances,  the  foot  may  be 


132 


THE    SURGICAL   PROCEDURES 


grasped  through  the  narrow   cervix,   and,  a   version   sling,   are 
sufficient. 

Narcosis  is  desirable,  though  occasions  may  arise,  as  in  severe 
anemia,  Avhen  it  may  have  to  be  omitted. 


Fig.   57. — Version  through  combined  interna!  and  external  manipulation.      (After  Braxton- 

Hicks-Bumm.) 

The  hand  of  the  operator  corresponding  to  the  side  of  the 
mother  in  which  the  child's  feet  lie,  is  passed  into  the  vagina. 
The  sac  is  ruptured  either  with  the  fingers  or  with  an  instru- 
ment.   The  presenting  part  is  pushed  to  one  side,  and  the  fingers 


VERSION 


133 


carried  as  high  as  they  will  go.  AVith  the  external  hand  on  the 
abdomen,  the  feet  are  pressed  downward,  the  purpose  being  to 
bring  them  within  reach  of  the  other  hand.  (Fig.  58.)  As  soon 
as  a  foot  is  felt  and  unmistakably  diagnosed  as  such,  it  is  secured 


Fig.  58. — Combined  version  in  the  second  position  of  the  vertex;  placenta  previa 
marginalis.  The  whole  hand  is  introduced  into  the  vagina,  and  the  first  two  fingers 
passed  through  the  partially  opened  os.  With  the  other  hand  applied  to  the  mother's 
abdomen,  pressure  is  made  on  the  child's  back  and  buttocks,  the  aim  being  to  cause 
a  foot   to   come  down   within   reach    of  the   two    fingers   pressed   up   from  below. 

and  brought  down  as  in  internal  version  just  described.  When 
far  enough  down,  a  sling  may  be  applied  to  the  ankle,  and  the 
foot  held  while  the  head  of  the  child  is  pushed  toward  the  fundus. 


134  THE   SUEGICAL   PROCEDURES 

THE  DIFFICULTIES  ENCOUNTERED  IN  PERFORMING 

VERSION 

In  describing  internal  and  combined  version,  noncomplicated 
cases  have  been  borne  in  mind.  There  are,  however,  many  difficul- 
ties to  be  encountered.  The  very  first  step  of  the  operation,  that 
of  passing  the  hand  into  the  vagina,  is  sometimes  very  hard  to 
take,  especially  in  an  elderly  primipara.  Also  the  canal  may  be 
obstructed  by  the  prolapse  of  an  arm,  which  is  particularly  apt  to 
occur  in  cross-births.  An  attempt  to  restore  it  would  be  a  mis- 
take, for  the  arm  readily  follows  the  head  as  turning  takes  place. 
And  again,  the  condition  of  the  uterus  itself  may  be  a  complica- 
tion. Undertaken  before  the  sac  has  ruptured,  or  shortly  there- 
after, version  is  not  hampered  bj'^  the  narroAved  space  within  the 
cavity ;  one  finds  ample  room  between  the  walls  of  the  uterus 
?nd  the  child's  body  to  operate.  And  even  if  the  liquor  amnii  has 
drained  away,  ancl  the  walls  lie  contracted  about  the  child,  the 
reduced  size  offers  no  serious  difficulty,  if  labor  has  not  begun. 
But  the  situation  is  quite  different  if  it  has;  for  the  organ  will  not 
then,  relax,  the  hand  becomes  cramped,  the  child  fixed,  and  fur- 
ther manipulations  do  more  harm  than  good.  Unless  one  is  able 
to  do  within  a  reasonably  short  time  what  he  starts  out  to  do,  he 
had  better  not  attempt  the  operation  at  all ;  for  version  is  one  of 
the  procedures  that  prolonged  effort  only  makes  increasingly 
difficult. 

And  not  only  is  the  uterus  wrought  up  by  manipulation,  but  it 
is  stimulated  even  to  greater  activity  by  the  administration  of 
ergot  and  pituitary  extract  indiscriminately  given.  When  thus 
excited,  the  best  thing  for  the  operator  to  do  is  to  induce  rest. 
Hot  packs,  the  prolonged  hot  bath,  and  time  help  to  relieve  the 
rigidity ;  but  the  remedy  par  excellence  in  such  conditions  is  mor- 
phine with  atropine  given  hypodermatically.  Version  can  usually 
be  performed  after  a  few  hours  of  such  treatment. 

If,  upon  full  dilatation  of  the  cervix,  the  fetus  does  not  ad- 
vance, the  effect  of  labor  is  to  cause  a  thinning  out  of  the  loAver 
segment  of  the  uterus,  the  walls  becoming  powerless  from  over- 
distention  and  in  imminent  danger  of  rupturing.  To  attempt 
version  under  such  circumstances  would  be  to  court  disaster. 
(See  Eupture  of  the  Uterus,  page  308.) 


VERSION  135 

In  undertaking  a  difficult  version,  then,  one  should  consider 
the  dangers  accompanying  it,  and  proceed  accordingly.  The  hand 
is  passed  slowly  and  carefully  along  the  side  of  the  advancing 
part,  yet  more  cautiously  between  the  child  and  the  wall  of  the 
uterus.  The  contracting  ring  of  Bandl  is  to  be  passed  only  in  the 
interval  of  a  pain.  Beyond  this  segment,  movement  is  freer,  and 
the  benumbed  hand  may  be  relaxed  and  rested. 

The  foot,  once  secured,  should  be  brought  slowly  through  the 
stretched  canal.  Sometimes  the  constriction  is  so  marked  that  the 
grasped  foot  can  not  be  brought  through  with  the  hand  closed, 
and  the  movement  must  be  managed  with  the  thumb  pressing  the 
foot  against  the  palm,  or  with  it  held  between  two  extended 
fingers. 

The  acme  of  danger  is  reached  when  the  child  turns,  when  it 
lies  for  a  brief  moment  wholly  crosswise  in  the  canal. 

If  the  simple  procedure  of  pushing  up  on  the  head  with  the  one 
hand  while  draAving  down  on  the  foot  with  the  other,  does  not  suc- 
ceed, one  may  try  the  version  sling.  With  this  device  the  ex- 
tremity can  be  held  more  securely  than  is  possible  with  the  fingers. 

Instead  of  attempting  externally  to  dislodge  the  head  while 
pulling  on  the  foot,  it  is  sometimes  more  effective  to  make  the 
upward  pressure  with  the  hand  in  the  vagina,  a  maneuver  known 
as  the  countermanipulation  of  Siegemundin  (Fig.  59). 

A  maneuver,  suggested  by  Broese,  of  la3dng  the  hand  flatwise 
along  the  side  of  the  head,  betAveen  it  and  the  uterine  wall,  has 
certain  advantages.  The  palm  acts  as  a  grooved  director,  while 
with  the  heel  of  the  hand  intermittent  or  continuous  pressure  may 
be  made  in  an  upAvard  direction  on  the  head.  Simultaneous  trac- 
tion on  the  foot  is  continued  as  in  the  other  method. 

But  not  all  the  difficulties  of  Aversion  are  due  to  conditions  of 
the  mother;  the  fetus,  as  Avell,  may  present  complications.  The 
posture  it  assumes  may  be  so  confusing  that  one  is  puzzled  to 
locate  the  feet,  which  appear  to  haA^e  Avandered  from  the  place 
Avhere  they  ought  to  be.  Occasionally  the  free  leg  becomes  crossed 
over  the  one  pulled  down,  necessitating  its  dislodgment  before  ver- 
sion can  be  effected.  (Fig.  60.)  Very  large  children,  also,  can 
complicate  the  operation  by  their  unmanageable  bulk. 

Even  so  simple  an  act  as  rupturing  the  amnion,  is  not  alAva3^s 


136 


THE    SURGICAL    PROCEDURES 


Fig.  59. — Version  in  the  first  position  of  the  vertex,  showing  the  use  of  the  sling. 
Version  in  this  case  is  made  difficult  by  the  contraction  ring  of  Bandl.  With  a  sling 
fastened  to  both  feet  they  are  held  securely,  while  with  the  other  hand,  which  is  within 
the  uterus,  pressure  in  an  upward  direction  is  made  on  the  child's  head.  The  maneuver 
is  known  as  the   double  manipulation  of  Justine   Siegemundin. 


VERSION 


137 


easy,  especially  when  performed  during  combined  version.  The 
membrane  may  lie  so  loosely  in  the  cervical  opening  that  the 
fingers  can  not  get  hold  of  it,  making  instrumental  perforation 
necessary. 

When  the  foot  lies  extended  in  the  narrow  canal  of  the  cervix, 
making  it  impossible  to  get  hold  of  it  with  the  fingers,  one  may 
venture  to  grasp  it  with  placental  forceps. 


Fig.  60. — A  complicating  situation  in  a  transverse  position  after  a  fruitless  attempt 
to  turn.  Both  arms  and  one  foot  are  presenting;  the  other  fpot  is  held  in  the  flexure 
of  the  child's   neck. 


PROGNOSIS 

The  prognosis  in  external  version  is  good,  hardly  less  favorable 
than  in  spontaneous  birth.  In  the  other  forms,  internal  and 
combined,  the  dangers  are  increased  for  both  mother  and  child. 

Dangers  to  the  Mother 

Infection. — Although  the  hand  does  not  come  in  contact  with 
the  endometrium,  especially  its  placental  surface,  there  are  likely 
to  occur  abrasions  and  lacerations,  even  though  they  be  slight, 


138  THE    SURGICAL    PROCEDURES 

which  present  portals  of  entrance  for  infection.  The  danger  is 
somewhat  less  in  combined  version,  bnt  even  here  its  possibility  is 
to  be  borne  in  mind,  since  the  pnlled-down  leg  occludes  the  cervix 
and  retains  within  the  cavity  any  pathogenic  germs  which  may 
have  been  introduced  by  the  fingers. 

Lacerations  and  Other  Injuries. — If  the  vulva  and  vagina  are 
small  and  contracted,  one  will  be  likely  to  cause  injury  while 
introducing  the  hand  and  arm.  To  avoid  this,  the  introitus  is 
sometimes  purposely  incised,  the  aim  being  to  secure  a  clean- 
cut  wound  rather  than  an  irregular  tear.  The  tissues  may  also  be 
cautiously  stretched  with  the  colpeurynter  preliminary  to  passing 
the  hand,  since  its  forcible  introduction  may  seriously  injure  the 
uterovaginal  support,  particularly  if  no  counterpressure  is  made 
on  the  fundus.  Indeed,  one  of  the  worst  accidents  that  can  hap- 
pen, rupture  of  the  uterus,  may  be  inflicted  in  this  way.  Such  a 
rupture  may  be  produced,  or  may  be  made  much  worse  in  com- 
pleting the  version  after  a  foot  has  been  drawn  down.  The  char- 
acteristic sign  of  such  an  injury  manifests  itself  by  the  sudden 
giving  way  of  the  resistance.  There  is  a  marked  relaxation  to  be 
noted  both  by  the  external  and  internal  hand ;  the  spherical  form 
of  the  uterus  becomes  flatter  and  more  irregular ;  and  the  version, 
which  seemed  impossible  a  moment  before,  is  now  easily  effected. 
The  consequences  are  very  serious,  the  mother  nearly  always 
dying. 

Dangers  to  the  Child 

As  to  the  child,  many  fatalities  accompany  the  operation ;  but  it 
is  not  always  fair  to  charge  them  to  the  turning  alone,  since  extrac- 
tion, so  frequently  to  foUoAV,  is  oftentimes  more  serious  than  the 
version  itself.  The  principal  danger  is  from  disturbed  fetal 
circulation.  The  operator  in  his  search  for  the  foot  may  inad- 
vertently compress  the  umbilical  cord,  or,  perhaps,  detach  a 
portion  of  the  placenta,  either  of  which  would  act  injuriously 
to  the  child.  The  manipulation  itself  also  tends  prematurely  to 
stimulate  respiratory  efforts.  And  while  it  is  true  that  the  sooner 
delivery  is  effected  after  version  has  been  accomplished,  the 
safer  it  will  be  for  the  child,  one  is  often  compelled  to  await  fur- 
ther dilatation  of  the  cervix  before  undertaking  it.    If  the  cervi?^ 


VERSION  139 

is  only  partially  dilated  and  extraction  is  impossible,  the  develop- 
ment of  alarming  s^'mptoms  puts  one  in  a  dilemma,  for  ver- 
sion, after  all,  is  but  one  step  in  the  operation  of  delivery;  the 
most  trying  part  of  the  ordeal  is  yet  to  folloAV. 

The  following  is  an  analysis  of  500  versions,  42  of  which  were 
external,  12'3  combined,  and  335  internal.  Only  8  per  cent  of 
the  whole  number  were  first  births. 

The  42  external  versions  w^ere  made  to  relieve  a  transverse 
presentation,  39  of  which  ended  in  spontaneous  birth.  Of  the 
other  three,  one  was  aided  by  extraction,  the  umbilical  cord  hav- 
ing prolapsed;  another,  in  an  occipitoposterior  position,  was 
turned  and  extracted;  and  the  other  was  a  breech,  converted  into 
a  head  and  delivered  with  forceps.  All  the  mothers  lived;  3  of 
the  children  were  born  dead. 

The  123  combined  versions  were  performed  upon  the  following 
indications: 

Placenta  previa  98  times 

Infection  11  times 

Eclampsia  7  times 
Premature  detachment  of  the  normally 

'                         placed  placenta  2  times 

Heart  failure  2  times 

Pneumonia  1  time 

Transverse  position  1  time 

Asphyxia  1  time 

Out  of  this  number  9  mothers  and  90  per  cent  of  the  children 
died. 

Internal  version  was  done  for: 

Transverse  or  oblique  i^osition  13.5  times 

Prolapsed  cord  61  times 

Asphyxia  of  the  child  40  times 

Contracted  pelvis  25  times 

Occipitoposterior  position  18  times 

Fever  16  times 

Eclampsia  14  times 

Btow  presentation  6  .times 

Marked  contraction  of  Bandl's  ring       4  times 

Prolapsed  arm  in  cross-birth  3  times 
Premature  detachment  of  the  placenta 

(twice  with  twins)  3  times 


140  THE   SURGICAL   PROCEDURES 

Face  position  in  contracted  pelvis  1  time 

Face  position,  arm  prolapsed  1  time 

Vitium  cordis  1  time 

Diabetic  coma  1  time 

Of  the  6  maternal  deaths,  4  ^vere  from  eclampsia,  1  from  infec- 
tion (previously  existing),  and  1  from  diabetic  coma.  Twenty- 
two  per  cent  of  the  children  were  born  dead.  {Taken  from  the 
reports  of  the  Koenigsherg  Clinic.) 


CHAPTER  yill 
BREECH-BIRTH 

Positions  of  the  breech,  like  positions  of  the  vertex  are  longi- 
tudinal, and  respond  much  the  same  to  the  natural  forces  of  labor. 
Indeed,  the  breech  position,  under  some  circumstances,  has  its 
advantages  over  the  vertex,  and  not  infrequently  is  it  secured 
designedly  in  order  to  serve  the  best  interests  of  both  mother  and 
child. 

If  the  presentation  is  diagnosed  during  pregnancy,  in  most  in- 
stances it  can  be  converted  into  a  vertex  by  external  version,  if 
this  is  desired.  If  it  is  discovered  only  after  labor  has  begun,  the 
patient  should  be  directed  to  conduct  herself  in  a  way  most  favor- 
able to  the  preservation  of  the  amnion,  since  its  premature  rup- 
ture delaj^s  dilatation  and  favors  prolapse  of  the  cord.  For  fear 
of  causing  such  an  accident,  one  should  make  all  necessary  ex- 
aminations with  great  precaution. 

A  Yery  important  preliminary  condition,  one  on  which  the  safety 
of  such  a  birth  depends,  is  full  and  complete  dilatation  of  the 
cervix.  When  the  breech  reaches  the  outlet  of  the  pelvis,  one 
may  be  assured  that  this  condition  has  been  fulfilled,  and  no  fur- 
ther proof  is  necessary ;  but  in  other  cases,  especially  in  foot  pres- 
entations, it  is  not  safe  to  assume  that  the  cervix  is  dilated,  for 
it  may  not  be.  In  order  to  make  sure,  the  whole  hand  should  be 
passed  into  the  canal  far  enough  to  palpate  the  internal  os;  but 
this  is  generally  too  much  of  an  ordeal  for  a  patient  to  undergo 
without  first  being  anesthetized. 

A  further  and  extremely  important  condition  upon  which  suc- 
cess depends  is  the  size  of  the  pelvis ;  it  must  be  large  enough 
to  give  passage  to  the  birth.  If  contracted,  other  procedures  than 
extraction  would  be  indicated.  (See  Indications  for  Cesarean 
Section,  page  243.) 

141 


142 


THE    SURGICAL   PROCEDURES 

TECHNIC  OF  EXTRACTION 


The  patient  is  placed  on  tlie  bed  crosswise  or  on  an  operating 
table,  and  disinfected.  In  easy  extraction  narcosis  is  not  required. 
In  fact  it  may  be  a  disadvantage,  in  that  it  interferes  with  the 
voluntary  efforts  of  the  patient  to  deliver  herself;  but  since  the 


Fig.  61. — Extraction  by  traction  on  the  foot.  First  step.  The  leg  below  the  knee  is 
grasped  with  both  hands,  the  thumbs  lying  parallel  on  the  calf.  Traction  is  made  down- 
ward. 


extraction  oftentimes  follows  upon  version,  the  patient  having 
already  been  narcotized  for  that  purpose,  her  help  can  not  be 
relied  upon  to  any  great  extent. 

The  process  of  extraction  should  resemble  spontaneous  birth 
as  closely  as  possible,  especially  Avith  regard  to  maintaining  the 


BREECH-BIRTH 


143 


normal  posture  of  the  child  and  the  preservation  of  the  normal 
mechanism.  The  nearer  we  imitate  the  evolution  of  nature,  the 
better  will  be  the  result;  and  no  result  is  counted  worthy  that 
does  not  save  life.     Expeditious  extraction,  for  example,  might 


Fig.  62. — ^Extraction.  Second  step.  The  thigh  is  grasped  with  both  hands,  the  thumbs 
lying  on  the  flexor  muscles.  Traction  is  made  downward,  followed  by  a  rotation  of  the 
hip    forward. 


save  the  baby's  life,  but  bring  with  it  a  severe  laceration  of  the 
mother's  tissues;  yet  this  would  be  counted  far  better  than  to 
lose  the  baby  in  an  attempt  to  conserve  the  structures  of  the 


144 


THE    SURGICAL   PROCEDURES 


motlier.    If  one  or  the  other  must  result,  the  child,  within  certain 
limitations,  should  receive  the  first  consideration. 

Extraction  of  Foot  Positions,  One  Foot  Presenting'. — While  the 
foot  is  still  within  the  vagina,  it  is  grasped  around  the  ankle 
with  the  right  hand  in  such  a  way  that  the  index  and  middle 
fingers  hook  over  the  maleoli,  their  palmar  surfaces  resting  on  the 


Fig.   63. — Extraction.     Third  step.     Traction  in  an  upward  direction  brings  the  anterior 
hip    against    the    symphysis,    and    permits    the    posterior    hip    to    rotate    over    the    perineum. 

dorsum  of  the  foot.  Strong  traction  is  made  dowuAvard,  the  toes 
pointing  toward  the  mother's  back,  the  flexed  surfaces  of  the 
leg  lying  to  the  front  under  the  pubic  arch.  After  the  foot 
is  born,  it  is  grasped  by  both  hands,  the  thumbs  lying  parallel 
on  the  calf  of  the  leg,  the  fingers  over  the  instep  (Fig.  61).  Trac- 
tion is  continued  downward.  When  delivered  up  to  the  knee,  the 
leg  is  held  with  the  thumb  lying  on  the  flexed  surface,  the  fingers 


BREECH-BIRTH 


14? 


Fig.  66. — Extraction.  Sixth  step.  Freeing  the  anterior  arm  from  under  the  symphysis. 
The  shoulder  lies  at  the  brim  of  the  pelvis;  the  arm  is  brought  down  by  the  finger 
hooked   in  the  flexure  of  the  elbow. 


148 


THE    SURGICAL   PROCEDURES 


Normally  the  shoulders  occupy  an  anteroposterior  position  at 
the  pelvic  outlet,  one  shoulder  back  of  the  symphysis  and  the 
other  in  the  hollow  of  the  sacrum,  the  arms  lying  crossed  upon  the 
breast.  The  freeing  of  the  posterior  arm,  owing  to  its  accessibility, 
is  much  easier  of  accomplishment  than  the  anterior.  To  do  it  the 
child  is  grasped  about  the  ankles  with  one  hand,  and  the  body 


Fig.  67. — Extraction.  Seventh  step.  Freeing  the  second  arm  from  the  hollow  of  the 
sacrum.  Traction  on  the  child's  body  is  made  upward  and  to  one  side;  two  fingers  of 
the  side  corresponding  to  that  of  the  child  are  passed  over  the  shoulder  and  the  arm 
stripped  downward  and   outward   as  shown   in   Fig.   68. 


strongly  elevated  and  moderately  flexed  toward  the  mother's  ab- 
domen. The  index  and  middle  fingers  of  the  operator's  other 
hand  are  passed  over  the  child's  shoulder  along  the  upper  arm 
to  the  elbow  and  on  down,  sweeping  the  arm  forward  over  the 
breast  and  abdomen.    In  order  to  free  the  second  arm,  which  now 


BREECH-BIRTH 


149 


lies  under  the  symphysis,  it  is  first  necessary  to  rotate  it  into 
the  hollow  of  the  sacrum,  after  which  it  is  brought  down  as  was 
the  first.     (Figs.  66-69.) 

Another  method,  somewhat  simpler  than  the  above,  is  to  pull 
the  anterior  arm  down  first.  This  is  done  by  making  strong  trac- 
tion on  the  child's  body  in  a  downward,  instead  of  in  an  upward, 


Fig.   68. — Extraction.      Freeing   the    second   arm,    as   seen    from   the    inside. 


direction,  until  the  upper  arm  comes  into  view,  when  it  is  easily 
freed  anteriorly  with  the  finger  (Fig.  66).  No  rotation  is  neces- 
sary in  order  to  get  the  posterior  arm,  for  it  already  lies  in  the 
hollow  of  the  sacrum  and  may  be  delivered  as  described  in  the 
first  instance. 

The  next  step  in  the  operation  of  extraction  is  the  delivery  of 


150 


THE   SURGICAL   PROCEDURES 


the  after-coming  head.  The  method  of  Veit-Smellie,  or  Mauriceau- 
Levret,  as  it  sometimes  is  called,  is  considered  the  most  satisfac- 
tory. A  finger,  first  or  second,  is  passed  into  the  child's  mouth 
as  far  back  as  the  base  of  the  tongue,  and  the  chin  drawn  down 
onto  the  breast,  the  child  lying  astride  the  operator's  arm.  With 
the  other  hand  the  baby  is  securely  grasped  about  the  shoulders, 
the  first  and  second  fingers,  fork-like,  passing  over  the  shoulder 


Fig.    69. — Extraction.      Freeing   the   posterior   arm,    viewed    from    witliin    the    pelvis. 

and  lying  at  the  side  of  the  neck  (Figs.  70  and  71).  Occasionally 
it  is  puzzling  to  find  the  mouth.  Usually  it  is  in  the  middle  line  ■ 
of  the  pelvis  or  slightly  to  one  side.  To  locate  it,  the  index 
finger  of  the  left  hand  is  passed  along  the  posterior  vaginal  wall 
until  it  comes  to  the  chin,  Avhich  is  recognized  by  the  angle  of 
the  jaw.     Traction  is  made  downward  until  the  occipital  pro- 


BREECH-BIRTH 


151 


tuberance  presses  under  the  symphysis ;  the  body  is  then  elevated, 
and  the  face  rotated  over  the  perineum. 

It  should  also  be  remembered  that  in  freeing'  the  arm  the  head 


Fig.  70. — Extraction.  Eighth  step.  Delivery  of  the  after-coming  head  by  thei  Veit- 
Smellie  method.  The  child's  head  is  in  the  pelvis,  and  its  body  lies  astride  the  op- 
erator's left  arm.  With  two  lingers  of  the  operator's  left  hand  in  the  child's  mouth, 
and  two  fingers  of  his  other  hand  hooked  over  its  shoulders,  traction  is  made  in  a 
downward  direction  until  the  occipital  protuberance  passes  the  symphysis,  then  in  an 
upward   curve,    the   face   and    hrow    rotating    over   the   perineum. 


rotates  with  the  body.  In  more  than  half  the  cases  the  mouth 
will  be  found  on  the  side  opposite  to  which  it  was  when  the  first 
arm  was  brought  clown.     That  hand  is   employed  which  most 


152 


THE    SURGICAL   PKOCEDURES 


readily  reaches  the  mouth,  the  left  in  right  positions,  the  right  in 
left  positions  (Fig.  72).  If  the  month  is  not  fomid  on  the  side 
it  was  thought  to  be  on,  the  operator's  hand  is  changed. 

Extraction  in  Foot  Positions,  Both  Feet  Presenting'. — AYhen 
both  feet  present,  they  are  grasped  by  a  single  hand  in  the 
following  manner:  The  fingers  are  placed  around  the  two  ankles 
in  such  a  way  that  the  middle  finger  lies  between  and  separates 
them,  while  the  other  two  lie  externally,  the  thumb  and  little 


Fig.   71. — Veit-Smellie    method    of    delivering   the   after-coming   head    as    seen    from    within 

the  birth   canal. 


finger  coming  together  over  the  sole  of  the  foot.  After  their 
delivery  through  the  vulva,  a  foot  is  grasped  in  each  hand,  with 
the  thumbs  on  the  calf,  and  the  fingers  encircling  the  ankle  (Fig. 
73).  Delivery  from  this  point  on  is  the  same  as  has  been  de- 
scribed above. 

In  making  breech-extraction,  two  situations  are  to  be  con- 
sidered; viz.,  where  the  breech  lies  above  the  brim,  and  where  the 
breech  lies  below  the  brim. 

If  the  breech  lies  above  the  brim,  the  presentation  should  be 


BREECH-BIETH 


153 


converted  into  a  footling.  Two  to  four  fingers  are  passed  into 
the  uterus  and  along  the  anterior  surface  of  the  child  up  to  the 
knee.  The  leg  is  then  flexed  on  the  thigh  so  that  the -foot  lies 
against  the  buttock,  when  it  may  be  brought  down  and  delivered  in 
the  usual  way  (Fig.  74).  The  procedure  should  not  be  undertaken 
except  under  narcosis.  AA^hen  the  back  of  the  child  lies  toward 
the  mother's  back,  the  manipulations  are  more  difficult  than  when 


Fig.    72. — Delivering  the    after-coming  head    (Veit-Smellie   method)    when   it  lies   above 
the  pelvic  inlet.     The  mouth  is  turned  to  one   side.     Traction  is  made  sharply  downward. 

it  lies  in  the  anterior  position.  Turning  the  patient  on  the  side 
in  which  the  child's  feet  are  found  makes  it  easier  to  reach  them. 
In  the  second  situation,  where  the  breech  lies  below  the  brim,  the 
difficulties  of  extraction  are  considerably  increased.  With  the  breech 
of  the  child  wedged  into  the  excavation  of  the  pelvis,  the  jack-knife 
posture  makes  it  very  awkward  to  apply  traction  by  any  means. 
The  finger  is  always  safe  and  available,  but  it  can  not  always  be 


154 


THE    SURGICAL   PROCEDURES 


hooked  into  the  angle  of  the  groin ;  besides,  even  if  it  could,  the  fin- 
ger lacks  strength.  Only  in  the  easier  cases,  in  which  the  soft  parts  of- 
fer little  resistance,  can  extraction  be  managed  in  this  way  (Fig.  75) , 
To  supplement  the  finger,  or,  rather,  to  take  the  place  of  the 
finger,  instruments  have  been  devised  that  hook  into  the  groin 
or  pass  around  it,  upon  which  one  may  pull.     The  blunt  hook 


Fig.   7i. — Extraction,    both    feet    presenting.      Each    hand    grasps    a    leg,    the    thumbs    lying 
on    the    calves.      Traction    is    made    in    a    downward    direction. 


and  extraction  sling,  are  designed  for  this  purpose.  The  sling, 
while  less  dangerous  to  the  tissues  of  the  child  than  the  hook, 
is  harder  to  apply.  On  the  other  hand,  the  hook  is  easily  car- 
ried in  and  is  fairly  safe  of  adjustment,  the  danger  from  its  use 
Iving  in  the  amount  of  force  needed  to  draw  the  breech  through 


BREECH-BIRTH 


155 


the  soft  parts.     Irreparable  harm  may  be  done  the  child,  espe- 
cially to  the  hip  joint,  in  the  operation. 

Bunge  has  invented  a  metal  sling-carrier  which  can  be  passed 
into  position  like  the  ordinary  blunt  hook,  and  it  is  so  constructed 


Fig.  74. — Bringing  down  a  foot  in  the  breech  position.  The  hand  corresponding  to 
the  foot  sought  is  introduced  into  the  uterus.  It  is  then  passed  along  the  thigh  to  the 
knee   and   on   to    the   leg,   the   leg  fle'xed   and   the   foot   drawn    down. 


that  it  can  be  removed  or  left  in  place  while  traction  is  made 
on  the  flexible  sling  with  Avhich  it  is  armed.  The  instrument  is 
really  nothing  more  than  a  grooved  director  fashioned  into  the 
form  of  a  hook,  carrying  a  piece  of  rubber  tubing  of  the  proper 


156 


THE   SURGICAL   PROCEDURES 


size  (Fig.  76).  With  it  the  advantages  of  both  hook  and  sling  are 
to  be  obtained.  Its  introduction  is  not  especially  difficult.  Held 
in  the  right  hand,  it  is  passed  under  guidance  of  the  first  and 
second  fingers  of  the  left  hand  into  position  about  the  child's 
groin.    (Fig.  77.)    The  carrier  may  be  left  after  the  sling  has  been 


Fig.   75. — Extraction    completed    with   the    finger    in    the    groin    after    the    breech    has    been 
brought   down   by   some   other   means. 

placed;  or  it  may  be  removed,  whichever  suits  the  purpose  best 
(Figs.  78  and  79). 

The  blunt  hook  of  Smellie  is  another  instrument  designed  to  fit 
into  the  groin,  and  is  much  stronger  and  more  dangerous  than 
the  Bunge  carrier.  It  should  not  be  used  on  the  living  child 
(Fig.  80). 


BREECH-BIRTH 


157 


A  hook  that  gives  the  best  results  in  living  children  is  the 
breech  hook  of  Kiistner,  which  is  made  with  a  pelvic  curve  that 


Fig.  7(,.— 
Bunge's   sling 
carrier. 


Fig.   n. — Passing    the    Bunge    sling    carrier    about    the    thigh. 


makes  possible  its  application  to  the  posterior  groin  (Fig.  81). 
The  instrument  is  held  with  the  right  hand,  and,  under  the 
guidance  of  the  left,  is  introduced  along  the  sacral  curve  to  the 


158 


THE    SURGICAL   PROCEDURES 


groin  of  the  eliilcl  (Fig.  82).    Unless  the  introitus  is  relaxed,  it  is 
advisable  to  perfoi-m  episiotomy  before  attempting  to  place  the 


Fig.   78. — The   sling  carrier   in   position. 


hook  in  position.  Traction  is  made  do^-mvard  until  the  anterior 
hip  appears  nnder  the  symphysis,  when  the  direction  should  be 
upward,  the  posterior  buttock  rotating  over  the  perineum. 


feREECH-BIRTIt 


159 


The  use  of  hooks,  fortunately,  is  not  often  necessary.     Either 
the  breech  remains  so  high  above  the  brim  that  a  foot  can  be 


Fig.   79. — The  sling  carrier   removed,   and  the  sling   in   place   ready   for   traction. 

brought  down,  or  so  low  that  the  groin  can  be  reached  with  the 
finger.    If  one  has  reason  to  believe  that  a  given  breech-birth  is 


160 


THE    SURGICAL   PROCEDURES 


going  to  be  difficult,  it  is  ^vise,  as  a  prophylactic  measure,  to  bring 
clown  a  foot  before  the  breech  becomes  immobilized  in  the  pelvis. 


Fig.   80. — Smellie's   blunt  hook. 


Fig.   81. — Kiistner's    breech    hook. 


Fig.   82. — Extraction    with    the    Kiistner    hook.       (The    foregoing    figures    illustrating    the 
operations    of    version    and    extraction,    are    copied    after    Hammerschlag.) 


(For  the  application  of  forceps  in  breech  positions,  see  the  suc- 
ceeding chapter.) 


BREECH-BIRTH  161 

THE  DIFFICULTIES  ENCOUNTERED  IN  BIRTH  BY 
THE  BREECH 

In  Extracting  the  Buttocks.— When  the  breech  reaches  the  mlet 
of  the  pelvis,  Avhich  occurs  about  the  time  the  knee  appears  at 
the  vulva,  progress  may  become  arrested.  There  are  two  causes 
for  this  arrest.  One  is,  that  the  breech  undertakes  to  enter  the 
pelvis  with  its  intertrochanteric  diameter  directed  anteroposteri- 
orly;  the  other  is,  that,  either  from  its  falling  down  or  its  being 
pulled  down,  the  posterior  foot  causes  the  anterior  hip  to  override 
the  symphysis.  Both  of  these  conditions  are  more  likely  to  occur 
when  the  maternal  pelvis  is  contracted. 

Since  the  breech  must  enter  the  pelvis  either  transversely  or 
obliquely,  the  proper  treatment  is  to  draw  the  anterior  foot  to 
one  side,  thus  favoring  the  rotation  of  the  back  toward  the  moth- 
er's abdomen. 

When,  from  overriding  of  the  s^'mphysis,  progress  becomes  ar- 
rested, the  anterior  hip  may  be  pulled  under  the  arch  by  making 
traction  sharply  dowuAvard  on  the  anterior  foot. 

Freeing  the  Arms. — If,  instead  of  remaining  flexed  on  the 
breast,  the  arms  Ijecome  extended,  they  must  be  brought  down 
before  the  head  can  be  born.  This  sometimes  makes  it  necessary 
to  introduce  the  whole  hand  into  the  canal.  But  only  when  the 
arms  can  not  be  reached  with  the  fingers  should  this  be  done. 
Even  then  it  is  well  to  first  incise  the  introital  ring  laterally.  Such 
extension  of  the  arms  almost  ahvays  occurs  if  the  mother's  pelvis 
is  contracted ;  and  continued  traction  only  tends  to  increase  the 
immobilization  of  the  fetus.  To  avoid  such  a  complication  one 
should  try  to  correct  the  displacement  before  drawing  the  breech 
too  low ;  and  before  delivering  to  the  angle  of  the  scapula,  the 
hand  should  be  introduced  and  the  arms  freed.  If  the  breech  is 
already  in  a  low  position,  with  the  arms  extended,  and  it  is  found 
impossible  to  free  them  in  this  way,  strong  traction  is  made  down- 
ward and  backward,  in  order  to  bring  the  anterior  shoulder 
within  reach,  when  the  arms  can  be  released,  as  previously  de- 
scribed. The  operation  requires  considerable  force,  and,  occa- 
sionally, is  accompanied  by  a  fracture  of  the  child's  arm. 

In  rotating  the  child,  as  must  be  done  in  order  to  bring  the  other 


162 


THE    SURGICAL   PROCEDURES 


Fig.  83. — Posterior  displacement  of  the  arm,  complicating  the  delivery  of  the  after- 
coming  head.  Its  release  can  be  accomplished  only  by  rotating  the  body  of  the  child  to 
the  left.      (Modified  from   Kerr.) 

shoulder  posteriorly,  there  is  great  clanger  of  the  arm  being 
twisted  into  a  position  back  of  the  neck.  (Fig.  83.)  To  prevent  this 
it  is  better  either  to  free  the  anterior  arm,  as  directed  above,  or, 
when  in  turning  the  shoulders,  to  always  turn  the  anterior  shoulder 


BREECH-BIRTH 


163 


Fig.   84. — Veit-Smellie    method   of   delivering   the    head   supplemented   by    external    pressure 

on  the  head. 


away  from  the  face.  Should  the  arm  once  become  fixed  behind  the 
head,  the  following  manipulations  for  its  release  are  suggested: 
First,  seek  to  free  the  arm  after  the  usual  method  of  pushing  it 
over  the   head   with  the   fingers;   next,    attempt  by   hooking   a 


164  THE    SURGICAL   PROCEDURES 

finger  in  the  elbow  to  carry  it  out  of  the  furrow.  Neither 
of  these  manipulations  succeeding,  the  breech  of  the  child  is 
turned  back  so  that  the  arm  to  be  released  will  lie  in  front.  The 
operator  now  passes  his  hand  along  the  abdominal  surface  of 
the  child  anteriorly  up  to  the  shoulder,  then  slipping  the  fingers 
posteriorly  they  are  hooked  into  the  elbow  and  the  arm  is  thrown 
off.  Still  failing,  the  arm  must  be  carried  doAvn  over  the  back,  a 
movement  not  without  considerable  danger  of  fracture. 

If,  in  the  process  of  extraction,  the  abdomen  of  the  child,  instead 
of  its  back,  is  brought  anteriorly,  generally  the  result  of  improper 
manipulation,  the  loosening  of  the  arm  may  become  extremely 
difficult.  In  this  case  the  operator  favors  rotation  while  making 
traction  on  the  breech.  Failing  in  this,  efforts  should  be  made 
early  to  loosen  the  arms,  which  may  call  for  the  introduction  of 
the  hand.  Upon  freeing  the  first  arm,  the  second  usually  follows 
without  much  difficulty. 

Delivering  the  After- Coming  Head. — AVhile  the  Veit-Smellie 
method  of  delivering  the  head  is  the  preferable  one,  and  should 
be  tried,  it  is  not  always  effective.  The  action  may  be  varied 
after  the  method  of  Wigand-Martin-Winkel ;  viz.,  by  pressing  on 
the  abdomen  of  the  patient  with  the  external  hand  instead  of 
making  traction  with  it  on  the  child's  shoulders;  or  the  Veit- 
Smellie  method  may  be  tried  again,  an  assistant  furnishing  the 
external  pressure  on  the  child's  head  (Fig.  84).  It  is  important 
that  the  pressure  be  made  with  the  whole  hand  or  the  two  fists 
evenly  applied;  otherwise  there  is  danger  of  inverting  the  uterus 
as  the  head  passes  out  of  the  cavity. 

If  all  the  aforementioned  maneuvers  fail,  they  should  be  gone 
over  again  with  the  patient  in  a  more  advantageous  position,  in 
the  lithotomy  position,  or  in  the  position  of  Walcher,  whereby 
there  is  gained  an  increased  conjugate  diameter  of  0.75  cm.  This 
increase  is  sometimes  sufficient  to  allow  the  head  to  pass. 

If  still  unsuccessful,  the  advantages  of  pubiotomy  should  be 
considered,  but  the  operation  should  not  be  undertaken  unless 
there  is  good  reason  to  believe  that  the  child  is  not  injured 
beyond  recovery.  In  case  there  is  good  reason  to  believe  that  it 
has  been 'so  injured,  or  that  it  is  already  dead,  perforation  is  in- 


BREECH-BIRTH 


165 


dicated.  After  performing  this,  the  Veit-Smellie  method  of  de- 
livery becomes  comparatively  easy. 

The  application  of  forceps  to  the  after-coming  head  is  a  per- 
fectly proper  procedure,  but  it  is  generally  undertake]i  too  late. 
If  other  methods  of  delivery  are  employed,  and  without  success, 
so  much  valuable  time  is  lost  thereby  that  delivery  with  the  for- 
ceps becomes  hopeless. 

Unfortunately  it  sometimes  happens  that  the  chin  rotates  to  the 


Fig.   85. — Delivery    of    the    after-coming    head    when    the    chin    lies    against    the    symphysis 
pubis.      (Prague   method. — Bumm.) 


front,  Avhere  it  hooks  onto  the  symphysis.  To  reach  the  mouth 
with  the  head  lying  in  this  position  is  practically  impossible;  and 
making  traction  on  the  child's  body  or  pressure  on  its  head  ex- 
ternally only  aggravates  the  conditions.  The  faulty  engagement 
must  first  be  corrected.  With  one  hand  grasping  the  occiput 
internally,  the  other  applied  to  the  chin  externally,  rotation  into 
an  oblique  diameter  is  possible.  The  Prague  method  (Fig.  85) 
is  to  grasp  the  child  by  the  shoulders  Avith  one  hand  Avhile  Avith 
the  other  the  legs  are  swept  over  the   mother's   abdomen   and 


166  THE   SURGICAL   PROCEDURES 

brought  strongly  to  one  side.    The  manipulation,  however,  is  not 
without  clanger  because  of  the  severe  torsion  on  the  child's  neck. 

THE  INJURIES  ACCOMPANYING  EXTRACTION 

Injuries  to  the  Mother. — Lacerations  of  the  soft  parts  may  be 
of  various  sorts  and  degrees,  particularly  when  the  extraction  is 
rapidly  made.  The  operation  frequently  demands  haste;  one  can 
not  always  await  dilatation.  Consequently,  more  or  less  injury 
to  the  cervix  and  perineum  are  to  be  expected  in  all  breech  ex- 
tractions, especially  in  the  primipara.  Owing  to  the  conical  shape 
of  the  advancing  part,  there  is  little  danger  of  lacerating  the  cer- 
vix until  after  the  shoulders  are  born.  If  the  head  is  then  forced 
through  the  resisting  cervix,  either  by  pulling  on  the  child's 
body  from  below  or  by  pressing  on  the  head  from  above,  a  severe 
laceration  is  likely  to  occur. 

If,  in  attempting  to  deliver  the  head,  the  cervix  is  brought  down 
to  the  vulva,  one  is  confronted  with  the  necessity  of  doing  one 
of  two  things — giving  the  tissues  time  to  stretch,  or  cutting  the 
resisting  structures.  Generally  speaking,  the  situation  concerns 
the  child  more  than  the  mother.  The  mother  can  well  afford  to 
suffer  an  injur}-  if  the  life  of  the  child  is  saved.  Therefore,  if  it  has 
been  ascertained  that  only  the  external  os  remains  to  be  dilated, 
there  should  be  no  hesitancy  in  cutting  it  with  the  scissors.  On  the 
other  hand,  if  the  resistance  is  due  to  the  internal  os,  one  dare 
not  cut  with  such  freedom.  By  making  slow  traction  after  the 
method  of  Veit-Smellie,  it  is  generally  possible  to  free  the  face  of 
the  child,  leaving  only  the  posterior  hemisphere  of  the  head  to 
be  born.  In  this  way  the  child  may  survive  for  a  considerable 
time,  long  enough  to  allow  the  cervix  to  dilate  without  laceration 
or  the  need  of  incision. 

The  gravity  of  a  cervical  laceration  depends  chiefly  on  the  in- 
volvement of  the  uterine  artery.  When  this  vessel  is  torn  there 
is  an  immediate  hemorrhage  following  the  birth  of  the  child.  The 
child's  head  itself  is  usually  covered  with  blood.  Should  such 
an  injury  occur  in  hospital  practice,  the  bleeding  would  be  con- 
trolled immediately  by  repairing  the  laceration.  In  the  home  this 
is  not  always  practicable;  and,  instead  of  suturing  the  parts,  the 
hemorrhage  may  have  to  be  controlled  by  packing. 


BREECH-BIRTH  167 

Other  portions  of  the  birth  canal  as  Avell  as  the  cervix  may  be 
injured  by  extraction,  especially  in  first  labors.  The  structure 
most  likely  to  suffer  is  the  perineum,  the  injuries  of  which  are 
treated  by  immediate  repair. 

Injuries  to  the  Child. — A  careful  inspection  of  the  child  should 
be  made  after  its  extraction.  The  continuity  of  the  tissues,  espe- 
cially of  the  bones  and  joints,  should  be  determined;  crepitation 
and  dislocations  should  be  sought  for ;  pathologic  mobility  deter- 
mined by  observing  the  imperfect  use  by  the  child  of  an  ex- 
tremity ;  and,  eventually,  if  there  is  any  doubt,  the  examination 
should  be  supplemented  by  radiography.  It  may  be  remarked  in 
this  connection,  though,  that  the  x-ray  does  not  satisfactorily 
show  the  lesion  of  a  loosened  epiphysis. 

Injuries  may  occur  to  the  lower  extremities,  to  the  body,  to  the 
upper  extremities,  and  to  the  head. 

Most  of  the  injuries  to  the  lower  extremities  come  from  making 
torsion  instead  of  traction ;  an  epiphysis  may  become  loosened,  a 
joint  lacerated,  or  a  thigh  fractured  thereby.  The  mechanical 
principle  involved  in  delivering  the  upper  arm  is  one  of  leverage, 
and  as  a  consequence  the  trauma  inflicted  is  more  often  that  of 
fracture,  the  most  frequent  member  to  suffer  being  the  humerus. 
In  bringing  down  the  arms  it  may  be  that  the  operator's  fingers 
were  not  carried  high  enough;  instead  of  hooking  them  into  the 
flexure  of  the  elbow,  an  effort  was  made  to  free  the  arm  by  ex- 
erting force  too  near  the  shoulder. 

Another  bone  often  broken  is  the  clavicle.  It  may  be  fractured 
by  direct  pressure  in  the  Veit-Smellie  procedure,  the  fingers  bear- 
ing too  firmly  upon  it  in  making  traction;  or  it  may  be  fractured 
by  indirect  pressure  when  much  force  is  used  to  bring  down  an 
arm. 

Fractures  of  the  forearm  are  of  rare  occurrence,  and  come  from 
making  too  strong  traction  below  the  elbow.  Both  bones  are 
more  likely  to  be  broken  than  a  single  one,  though  of  the  two  the 
radius  is  in  greater  danger  than  the  ulna. 

The  outcome  of  most  fractures  is  good.  A  simple  splint  worn 
for  a  fortnight  is  generally  sufficient  to  insure  union.  Fractures 
of  the  humerus  and  clavicle  which  can  be  made  out  by  abnormal 
mobility,  crepitation,  and  disturbed  function,  are  best  treated  by 


168  THE    SURGICAL   PROCEDURES 

placing  a  pad  in  the  axilla,  and  immobilizing  the  arm  on  the 
breast.  A  broken  leg  or  thigh  may  be  splinted  to  the  opposite 
member.  Epiphyseal  injuries  are  less  amenable  to  treatment. 
Their  management  is  similar  to  the  above,  bnt  the  results  are 
not  so  satisfactory.  Occasionally  the  injurj^  is  followed  by  a 
luxation. 

The  location  of  a  fracture  is  disclosed  by  the  sensation  of 
crepitation  over  the  fracture  point,  by  the  displacement  of  the 
ends  of  the  bones,  and  by  the  roentgen  rays.  Such  an  injury 
to  the  upper  end  of  the  humerus  gives  abnormal  mobility  re- 
sembling dislocation. 

A  condition  resembling  epiphyseal  luxation  is  observed  in 
serious  injury  to  the  nerves,  caused  through  pressure  of  the 
fingers  in  the  Yeit-Smellie  manipulation.  The  reaction  of  de- 
generation, disclosed  through  use  of  the  galvanic  current,  will 
establish  the  paralysis  later. 

Some  of  the  more  unusual  injuries  of  the  body  are  rupture  of 
the  liver  and  dislocation  of  the  vertebra.  Either  would  be  fatal. 
Nor  is  it  unheard  of  for  the  body  of  the  child  to  be  torn  away 
from  the  head.     (See  Decapitation,  page  228.) 

Injuries  to  the  head  are,  for  the  most  part,  the  result  of  dis- 
proportion. Obviously,  a  large  head  dragged  or  pushed  through 
a  small  pelvis  is  apt  to  do  damage,  not  only  to  the  maternal  parts, 
but  to  the  fetus,  as  well.  Trauma  of  the  scalp  may  produce 
only  a  hematoma,  but  sometimes  the  injur-y  amounts  to  an  open 
wound.  The  forces  of  nature  alone  seldom  cause  such  injuries ; 
they  are  more  likeh^  to  be  produced  by  too  much  pressure  from 
the  outside,  as  when  an  assistant  pushes  on  the  head  from  above 
the  symphysis.  The  exertion  of  immoderate  force  in  this  way  is 
capable  of  doing  great  damage.  Under  certain  circumstances 
the  cranial  vessels  may  be  ruptured,  and  serious  hemorrhage  into 
the  meninges  may  follow.  Likewise,  it  is  possible  to  fracture 
the  skull  or  to  tear  loose  the  fascia  at  the  base  of  the  occiput. 
The  indentation  of  a  parietal  bone  at  the  point  where  it  passes 
over  the  promontory  of  the  sacrum,  the  so-called  "spoon-shaped" 
depression,  is  a  fairly  common  injury  in  obstetrics  (Fig.  86).  If 
the  bone  is  not  fractured,  it  may  spring  out  again  of  itself ;  other- 
wise the  depression  may  persist,  and,  if  the  injury  has  not  caused 


BREECH-BIRTH 


169 


an  intracranial  hemorrhage,  the  child  may  grow  up  with  an  in- 
verted bump. 

If,  in  following  out  the  Veit-Smellie  technic  of  delivering  the 
after-coming  head,  the  fingers  are  not  carried  well  into  the 
mouth,  there  is  danger  of  fracturing  the  lower  jaw. 

Such  injuries  of  the  head  as  have  been  mentioned,  except 
hematoma  and  abrasions  of  the  scalp,  may  easily  prove  fatal. 
The  expectant  treatment  otfers  some  hope,  and  is  sufficient  in 
many  cases.  The  spoon-shaped  depression  of  the  parietal  bone 
may  be  corrected  by  drawing  it  out  with  an  instrument  fashioned 
like  a  corkscrew,  caution  being  taken  not  to  introduce  the  in- 


Fig.   86. — Spoon-shaped   depression    in   the   parietal   bone. 

strument  far  enough  to  injure  the  meninges.    The  bone  generally 
snaps  out  after  a  few  moments  of  elevation. 


PROGNOSIS 

For  the  mother,  a  breech-birth  is  not  accompanied  by  very 
great  danger.     Only  through  interference  and  the  application  of 


170  THE    SURGICAL    PROCEDrEES 

force  is  sucli  a  birtli  made  clisadvantageous  to  lier.  But,  on  the 
other  hand,  a  breech-birth  greatly  increases  the  dangers  for  the 
child.  Through  possible  asphyxia,  and  the  forcible  manipula- 
tions often  made  necessary,  the  prognosis  becomes  serious. 


CHAPTER  IX 
FOECEPS  OPEEATIONS 

The  forceps  is  an  instrument  of  two  parts  not  unlike  two 
spoons,  made  in  complement  and  so  formed  that  each  half  can 
be  introduced  separately,  adjusted  to  the  child's  head,  and 
locked.  Thus  afhxed,  traction  may,  within  certain  limita- 
tions, be  applied  without  harm  to  the  mother  or  child.  Theo- 
retically, the  action  of  the  forceps  is  one  of  traction;  but,  inas- 
much as  its  hold  on  the  child's  head  is  secured  by  pressure,  this 
will  vary  somewhat  with  the  amount  of  force  exerted  in  effect- 
ing delivery,  and  herein  lies  the  chief  danger  in  its  use. 

The  pattern  of  forceps  generally  recommended  is  the  Simpson 
or  some  modification  of  it  (Fig.  89).  Personally,  I  have  be- 
come attached  to  the  McLane  instrument.  With  it  I  find 
that  I  can  accomplish  more,  and  injure  the  child  less,  than 
with  any  other  forceps.  The  axis-traction  bar  of  McClintock  is 
a  fairly  good  substitute  for  the  Tarnier  forceps,  and  is  quickly 
applied  (Fig.  90). 

The  ideal  forceps  is  light  in  construction,  and  is  made  of  hand- 
forged  steel.  A  cheap,  poorly  made  instrument  is  worse  than  use- 
less ;  it  is  dangerous. 

INDICATIONS  AND  CONDITIONS 

The  forceps  is  indicated  whenever  it  will  relieve  a  situation 
that  can  not  be  relieved  better,  or  at  least  as  well,  by  some  other 
measure.    Its  use  will  be  discussed  from  this  point  of  view. 

Asphyxia  of  the  child  is,  perhaps,  the  most  frequent  indication 
for  the  use  of  forceps.  The  symptoms  are  discharge  of  meconium, 
marked  alteration  in  the  fetal  heart  sounds,  and  an  effort  on  the 
part  of  the  child  to  breathe. 

From  the  mother's  standpoint  prolonged  labor  without  prog- 
ress suggests  the  use  of  forceps.     Sometimes  when  dilatation  is 

171 


172 


THE    SURGICAL   PROCEDURES 


complete,  the  head  well  down  on  the  pelvic  floor,  and  the  forces  of 
labor  spent,  a  woman  will  complete  her  delivery  if  she  is  di- 
rected to  "bear  down"  while  the  accoucheur  makes  external 
pressure  on  the  abdomen.  The  expedient  failing,  a  small  dose 
of  pituitary  extract  should  be  given;  then,  and  not  until  then, 
the  forceps  may  be  employed. 

Birth  may  come  to  a  standstill,  and  remain  quiescent  for  hours. 
If  no  danger  exists  for  either  mother  or  child,  one  can  well  af- 
ford to  try  other  expedients  before  resorting  to  forceps.     Some- 


Fig.  87. — Chamberlen's  forceps. 

times  a  short  rest  under  the  influence  of  narcosis  will  be  followed 
by  renewed  efforts.  The  narcosis  also  tends  to  dispel  the  pa- 
tient's fear,  and,  instead  of  holding  back,  she  will  make  more 
use  of  the  voluntary  muscles  of  the  aMomen. 

There  is  a  limit,  however,  to  the  prolongation  of  fruitless  labor. 
Continued  indefinitely,  changes  of  an  undesirable  character  are 
likely  to  follow.  Decomposition  of  the  amniotic  fluid  through 
entrance  of  microorganisms,  with  consequent  infection,  has  al- 
ready been  referred  to.  It  is  best,  therefore,  not  to  w^ait  more 
than  a  few  hours  at  most  before  bringing  labor  to  a  close.    When 


FORCEPS    OPERATIONS 


173 


the  head  is  Ioav,  the  soft  parts  well  stretched,  and  the  position  of 
the  fetus  normal,  the  operation  of  delivering  with  forceps  is 
practically  harmless. 


Fig.   88. — Eevret's   long   forceps,    and    Sniel- 
lie's   short   forceps. 


Fig.   89. — Brown-Simpson    forceps. 


Four  conditions  must  be  fulfilled  before  attempting  to  deliver 
with  forceps:  (1)  The  amniotic  sac  must  be  ruptured;  (2)  the 
fetal  head  must  not  be  above  the  average  size  and  firmness;  (3) 


174 


THE   SURGICAL   PROCEDURES 


the  mouth  of  the  uteru.s  must  be  fully  dilated;  and  (4)  the  head 
must  be  engaged.  To  undertake  the  operation  with  one  or  the 
other  of  these  conditions  unsatisfied  is  a  mistake ;  yet  such  mis- 
takes are  only  too  often  made. 

To  apply  forceps  to  the  fetal  head  between  the  membranes 
and  the  uterine  Avail  is  not  only  a  difficult  thing  to  do,  but  the 
attempt  would  be  accompanied  by  severe  hemorrhage.  So,  be- 
fore introducing  the  blades,  one  must  positively  know  that  the 
sac  is  ruptured.  Sometimes  this  is  not  easily  made  out,  espe- 
cially when,  in  the  absence   of  forewaters,   the   membranes  lie 


Fig.   90. — Tucker-McLane   forceps   with   McClintock   axis-traction   bar   applied. 

close  to  the  head.  The  child's  hair  can  usually  be  felt  if  the 
sac  has  ruptured;  yet  even  then  it  is  sometimes  puzzling  with 
the  gloved  fingers  to  say  that  it  is  not  covered  with  membrane. 
In  doubtful  cases  one  can  tell  whether  the  sac  is  ruptured  by 
pressing  the  head  upward.  If  ruptured,  fluid  will  escape;  if 
not,  the  sac  becomes  distended,  as  it  overlies  the  head. 

The  cephalic  curve  of  the  forceps  is  designed  to  fit  the  average- 
sized  head;  but,  while  it  is  competent  to  seize  and  hold  a  head 
slightly  smaller  or  larger,  the  instrument's  range  of  utility  is 
more   limited   than   is   commonly   believed.     In   undertaking,    for 


FORCEPS    OPERATIONS  175 

example  the  extraction  of  a  six-months  fetus  with  it,  the  head 
can  not  be  held.  It  is  occasionally  possible  to  deliver  a  hydro- 
cephalic fetus  with  forceps,  but  the  condition  must  be  of  light 
degree,  and  the  head  partially  engaged  and  of  moldable  type. 

The  mouth  of  the  uterus  should  be  open.  This  rule  admits  of 
some  variation  in  case  the  mother  or  child  is  in  danger.  Even 
then  it  may  be  wise  to  take  time  to  complete  the  dilatation  ar- 
tificially, or  to  open  the  cervix  by  means  of  incisions,  or,  i3os- 
sibly,  to  perform  vaginal  cesarean  section.  When  the  head  lies 
within  the  pelvis,  and  the  os  uteri  is  not  only  dilated,  but  re- 
tracted bej^ond  reach  of  the  examining  finger,  we  have  the  most 
favorable  situation  for  the  proper  use  of  forceps.  The  cervical 
canal  may  be  obliterated  without  the  external  os  having  entirely 
disappeared,  when,  under  such  circumstances,  it  is  permissible 
to  apply  forceps,  counting  on  the  head  to  complete  the  dilatation. 
In  doing  so  it  hardly  need  be  added  that  traction  should  be 
made  cautiously  and  slowly. 

The  head  must  be  engaged.  This  is  very  important.  Many 
failures  and  most  serious  consequences  come  from  not  adhering 
to  the  rule.  One  can  be  deceived  into  believing  that  the  head 
has  entered  the  pelvis  when  it  has  not.  Even  when  the  head  is 
easily  reached  with  the  finger,  or,  possibly,  is  seen  through  the 
vulva,  it  may  not  have  passed  the  superior  strait.  Especially  is 
this  true  in  cases  of  fiat  pelvis. 

There  are  two  methods  of  determining  whether  or  not  the  head 
is  engaged.  One  is  the  usual  bimanual  examination,  by  which  it 
is  estimated  how  much  of  the  head  lies  above  and  how  much  be- 
low the  inlet.  The  other  method  is  by  external  manipulation 
alone.  In  either  case  one  depends  on  the  relation  the  head  bears 
to  the  linea  innominata;  that  is,  whether  it  lies  entirely  above  it, 
or  has  started  to  pass  through  it,  or  lies  entirely  beloAv  it. 

If  the  head  lies  above  the  inlet,  it  can  be  grasped  with  the  ex- 
ternal hand  above  the  symphysis  while  with  the  internal  hand 
the  obstetric  conjugate  can  be  spanned  with  the  fingers.  This 
would  be  a  contraindication  for  forceps. 

If  a  part,  of  the  head  remains  above  the  inlet  while  another 
part  is  felt  in  the  excavation,  or  if  the  parietal  eminences  have 
passed  beyond  the  linea  innominata,   so  that   the   upper  three 


176 


THE    SURGICAL    PROCEDURES 


sacral  vertebrge  and  tAvo-thirds  of  the  sjnnpliysis  anteriorly  can 
be  palpated,  the  head  may  be  said  to  be  engaged.  Here  forceps 
is  permissible. 

One  .shonld  bear  in  mind  that  the  head  is  constantly  undergo- 
ing changes  of  contour,  and  that  nature  is  competent  in  most 
instances  to  mold  it  to  fit  the  passages. 


Fig.  91. — Application  of  the  left  blade  of  the  forceps.  The  left  blade  is  taken  in  the 
left  hand  as  one  would  hold  a  pen.  Two  fingers  of  the  right  hand  are  introduced  into 
the  vagina,  and  applied  with  their  palmar  surface  to  the  child's  head.  Between^  them 
and  the  head  is  passed  the  blade  of  the  forceps.  The  thumb  of  the  same  hand  is  em- 
ploj'ed   to   support   and   urge   it   forward. 

METHOD  OF  PROCEDURE 

The  instruments  required  in  the  operation  are  the  following: 
the  forceps,  a  tissue  forceps,  artery  clamps,  a  strong  pair  of 
scissors,  a  needle-holder,  needles,  suture  material,  a  catheter,  and 
a  vaginal  speculum. 


FORCEPS    OPERATIONS 


177 


In  low  forceps  one  may  sometimes  venture  to  deliver  without 
changing  the  patient's  position,  it  being  very  easy  to  apply  for- 
ceps when  the  head  is  on  the  perineum;  otherwise  she  is  placed 
crosswise  on  the  bed,  the  thighs  flexed,  and  the  knees  separated. 
Thorough  disinfection  is  important. 

Narcosis  is  advised  unless  there  is  some  contraindication.  In 
low  positions  of  the  head  it  is  not  absolutely  necessary,  espe- 


Fig.   92. — Another  view   of  the   same   maneuver  as   illustrated  in   Fig.   91. 

cially  if  the  woman  has  borne  children ;  and  yet  it  is  humane  to 
allow  it.  If  given  at  all,  it  should  be  deep  enough  to  keep  the  pa- 
tient quiet;  for  nothing  is  more  annoying  than  to  have  her  twist 
out  of  position  during  the  operation. 

A  favorable  case  for  delivery,  it  may  be  repeated,  is  one  in 
which  the  head  is  found  low  in  the  pelvis,  the  os  uteri  fully  di- 
lated, and  the  advancing  part  adapted  to  the  bony  canal. 


178 


THE    SURGICAL   PEOCEDURES 


Upon  completing  the  necessary  preparations,  the  acconchenr 
seats  himself  before  the  patient,  stands,  if  preferred,  and  pro- 
ceeds as  foUo-ws:  The  left  blade  of  the  forceps  is  taken  in  the 
left  hand  (Fig.  91)  and  introduced  into  the  uterus  along  the 
left  side ;  the  right  blade  is  then  taken  in  the  right  hand  and  in- 
troduced into  the  uterus  along  the  right  side. 


Fig.  93. — Application  of  the  right  blade  of  the  forceps.  Held  like  a  pen,  the  right 
blade  is  taken  in  the  right  hand  and  the  handle  brought  well  over  the  right  groin.  Two 
fingers  of  the  left  hand'  are  passed  into  the  vagina,  the  nail  side  toward  the  dilated  mar- 
gin of  the  OS  uteri,  the  palmar  surface  applied  to  the  child's  scalp.  The  blade  of  the 
forceps  is   passed   between   the    fingers   and   the  head. 


The  manner  of  holding  the  blade  is  not  very  important;  but  I 
prefer  to  handle  it  like  a  spoon  or  a  pen,  instead  of  like  a  knife 
or  a  sword. 

The  left  blade  is  taken  in  the  left  hand,  as  described;  two 
fingers  of  the  right  hand  are  introduced  into  the  vagina,  keep- 


FORCEPS    OPERATIONS 


179 


ing  close  to  the  child's  head;  and  the  handle  of  the  blade  is  car- 
ried over  to  the  right  groin  of  the  mother  with  the  tip  of  the 
blade  directed  into  the  left  side  of  the  vagina  and  cautiously  slid 
along  the  palmar  surface  of  the  guiding  fingers.  As  the  blade 
passes  upAvard  and  imrard  the  handle  is  brought  forward  in  a 
curve  corresponding  to  the  pelvic  axis,  falling  to  the  middle 
line  and  resting  on  the  perineum.     While  the  index  and  middle 


Fig.   94.— Both   blades    have   been   introduced,   and   lie   unlocked,    resting   on   the   perineum. 

fingers  are  guiding  the  end  of  the  instrument  within  the  canal 
the  thumb  on  the  outside  aids  materially  as  a  fulcrum  (Fig.  92). 
The  placing  of  the  second  or  right  blade  (Fig.  93)  is  practically 
the  same  as  that  of  the  left,  except  that  opposite  hands  are  used 
in  the  various  manipulations  described.  When  in  position,  the 
second  blade  should  fall  on  top  of  the  first  and  lock  easily  (Fig. 
94.)  The  handle  of  the  left  blade  is  taken  in  the  left  hand,  the 
right  in  the  right,  with  the  thumb  lying  over  the  lock  on  the  re- 


180 


THE    SURGICAL   PROCEDURES 


spective  sides  (Fig.  95).  Some  effort  is  necessary  to  get  the  two 
halves  adjusted  and  securely  locked,  but  no  undue  force  is  per- 
missible  (Fig.  96). 

There  are  no  hard  and  fast  rules  as  to  how  the  forceps  shall  be 
held  when  making  traction ;  no  wrong  nor  right  way.  It  will 
naturally  be  grasped  to  the  best  advantage,  and  will  be  held 
in  every  conceivable  way  before  one  is  through  with  a  difficult 


Fig.   93. — Locking   the    blades. 

delivery.  On  either  side  of  the  lock  there  is  a  projecting  shoul- 
der, over  which  the  index  and  middle  fingers  are  hooked  advan- 
tageously. (Fig.  97.)  The  direction  in  which  traction  should  be 
made  depends  on  the  position  of  the  head.  If  it  is  low,  the  pull 
should  be  in  line  with  the  mother's  body;  if  extending  under  the 
symphysis,  it  would  be  almost  at  a  right  angle.  When  the  head 
is  above  the  brim  of  the  pelvis,  traction  is  at  first  toward  the 


FORCEPS    OPERATIONS 


181 


mother's  back,  then  m  line  with  her  body,  and  so  on,  varying 
with  the  axial  curve  as  the  head  moves  along  the  canal. 

To  avoid  compression  of  the  child's  head  some  instruments 
are  provided  with  an  adjustable  screw  at  the  end  of  the  handle 
which  keeps  the  blades  separated  to  any  desired  degree.  Most 
operators  depend  on  the  finger  for  this  purpose,  which  is  placed 
between  the  handles,   Avhile  others  use   a  piece   of  gauze  or   a 


Fig.   96. — Forceps  in  position   and  locked. 

folded  toAvel.  Obviously,  the  nearer  to  the  fulcrum  the  power 
is  applied,  the  less  will  be  the  force  at  the  distal  end  of  the  lever. 
This  fact  gives  to  the  axis-traction  forceps  its  chief  advantage, 
namely,  that  its  power  is  applied  above  the  lock. 

Any  forceps  delivery  which  requires  more  force  than  can  be 
applied  with  the  muscles  of  the  arm,  becomes  dangerous.  The 
operation  is  a  supplemental  application  of  force,  an  aid,  and  not 
a   supplanting   of   physiologic  power.     Likewise,   nature's   way 


182 


THE    SURGICAL   PROCEDURES 


should  be  emulated  in  the  manner  of  applying  force;  it  should 
be  rhythmical  and  intermittent,  not  continuous;  for  a  baby  is 
able  to  stand  a  moderate  force  extending  over  a  long  period  of 
time  better  than  a  greater  force  exerted  for  a  short  time.  Dur- 
ing the  rest  pauses,  one  should  listen  at  intervals  to  the  fetal 
heart.  An  assistant  may  make  the  examination ;  or,  the  operator 
can   listen   for   himself  by   manipulating   the   stethoscope   with 


Fig.   97. — Traction. 


sterile  gauze,  or  by  holding  it  v,-ith  a  sterile  rubber  band  (Fig. 
98). 

In  a  low  forceps  delivery  the  head  is  drawn  down  until  the 
occiput  is  well  under  the  symphysis.  When  this  point  is  reached, 
the  handles  are  gradually  elevated,  the  occiput  being  a  fixed  point 
around  which  the  brow,  face,  and  chin,  respectively,  revolve  as 
they  pass  over  the  perineum.  To  perform  this  part  of  the  op- 
eration most  advantageously,  the  obstetrician  stands  at  the  side 
of  the  mother,  generally  the  left  side,  grasps  the  forceps  above 


FORCEPS   OPERATIONS 


183 


the  lock,  or  about  it,  and  continues  the  traction  forward  and  up- 
ward. The  possibility  of  injuring  the  soft  parts,  particularly  the 
perineum,  is  always  to  be  borne  in  mind  when  using  the  forceps. 
Its  increased  volume  adds  to  the  danger,  and  it  can  happen  that 
the  posterior  edge  of  the  blades  will  cut  into  the  tissues  if  the 
handles  are  elevated  too  acutely. 


Fig.  98. — Ustening  to  the  fetal  heart  without  interrupting  asepsis.  The  stethoscope, 
placed  to  the  ears  of  the  surgeon  by  someone  other  than  himself,  can  be  moved  about 
by  means  of  a  sterile  rubber  band  looped  over  his  thumbs. 

With  the  left  hand,  if  one  stand  at  the  mother's  left,  the 
perineum  is  protected  by  regulating  the  advancement  of  the 
brow,  and  by  gently  stretching  the  taut  tissues  with  the  thumb 
and  index  fingers  (Fig.  99).  The  anterior  commissure  may  be 
pressed  back  in  a  similar  manner  thus  freeing  the  occiput. 

"When  the  head  no  longer  retreats  during  the  interim  between 


184 


THE    SURGICAL   PROCEDURES 


the  conti-actions,  it  may  be  fixed  with  the  fingers  pressed  over 
the  nose  or  chin,  externally,  of  course,  and  the  forceps  allowed 
to  remain  loose,  or,  better  still,  removed  altogether.  With  the 
fingers  protected  from  anal  contamination  by  the  interposition 
of  a  sterile  towel  or  dressing,  the  thumb  of  the  same  hand  rest- 
ing on  the  exposed  scalp,  one  can  slowly  express  the  head. 


Fig,  99. — As  soon  as  the  occipital  protuberance  has  passed  the  symphysis,  the  opera- 
tor takes  a  position  at  the  side  of  the-  patient.  With  one  hand  holding  the  forceps  and 
making  upward  traction,  the  other  supports  the  perineum  and  regulates  the  advance- 
ment of  the   head. 


After  the  head  is  fully  born,  the  occiput  is  urged  toward  the 
side  of  the  fetal  back;  and  the  head  is  taken  in  both  hands  by 
the  accoucheur,  and  pushed  rather  strongly  (Fig.  100)  against  the 
perineum.  This  brings  the  anterior  shoulder  under  the  symphysis. 
The  head  is  now  elevated  (Fig.  101)  and  slight  traction  made,  where- 
upon the  posterior  shoulder  slips  over  the  perineum.  The  body 
of  the  child  follows,  the  obstetrician  offering  only  supportive  as- 
sistance. 


FORCEPS    OPERATIONS 


185 


If  the  delivery  of  the  shoulders  is  sometimes  more  difficult 
than  such  description  Avould  imply,  rather  than  pull  danger- 
ously hard  on  the  head,  the  finger  should  be  passed  into  the 
axilla  and  traction  applied  there  instead.  Here,  again,  one 
must  be  careful  lest  the  delivery  of  the  shoulders  injure  the 
otherwise  intact  perineum. 


Fig.   100. — Depressing    the    head    in    freeing    the    anterior    shoulder.      There    is    danger    of 
causing  Erb's  palsy  if  too  much  force  is  used.      (Cumm.) 


Because  of  its  pelvic  curve  the  forceps  is  most  favorably 
placed  only  when  the  blades  are  in  the  transverse  diameter  of 
the  mother's  pelvis.  There  are,  however,  situations  in  Avhich  ro- 
tation of  the.head  has  not  assumed  this  advantageous  position, 
making  it  necessary  to  adjust  the  blades  at  a  different  angle, 
and  to  readjust  them  as  rotation  takes  place.     If,  for  example, 


186 


THE   SURGICAL   PEOCEDURES 


the  position  of  the  head  is  slightly  oblique,  so  that  the  small 
fontanel  lies  at  one  side,  the  blades  may  be  applied  laterally, 
and  rotation  completed  as  traction  goes  on.  Only  when  the  head 
lies  low  and  the  sagittal  suture  runs  crosswise,  or  nearly  so 
(deep  transverse  position  of  the  head),  rotation  being  arrested, 
must   the   forceps   be    applied   obliquely.      To   place    the   blades 


\^V  \ 


i^       V 


Fig.   101. — Elevating  the   head   in   freeing  the   posterior   shoulder.      (Bumm.) 

laterally  when  the  head  lies  in  this  position,  one  blade  would  rest 
over  the  brow,  the  other  over  the  occiput,  and  it  would  be  an  im- 
practicable and  dangerous  application  to  make.  It  would  be 
only  a  little  more  secure  if  the  head  stood  in  the  oblique  diameter, 
for  here  the  cephalic  curve  of  the  blades  embraces  the  brow  and 
occiput  more  to  the  side,  the  tip  of  one  blade  endangering  the 
eye,  the  other  pressing  deeply  into  the  suboccipital  space  back  of 
the  ear,  such  pressure  often  being  the  cause  of  facial  paralysis. 


FORCEPS    OPERATIONS 


187 


Tlie  object  always  is  to  bring  the  occiput  anteriorly;  and,  in 
order  to  do  this,  the  blades  of  the  forceps  must  lie  in  the  oppo- 
site obliquity  to  that  of  the  suture.  That  is,  if  the  suture  runs 
from  the  right  side  posteriorly  to  the  left  side  anteriorly,  or  is 
directly  transverse,  the  small  fontanel  in  either  case  lying  to  the 
left,  the  forceps  must  lie  from  the  left  posteriorly  toward  the 


Fig.   102. — Applying   the   left   blade   in   the    oblique  diameter   of   the   pelvis. 


right  anteriorly ;  and  vice  versa  if  the  head  occupies  the  opposite 
obliquity. 

If  the  forceps  is  to  be  applied  in  the  oblique  diameter  (Fig. 
102)  one  proceeds  as  follows:  The  first  or  left  blade  is  intro- 
duced in  the  usual  w^ay,  that  is,  in  the  left  oblique ;  and  made  to 
lie  in  front  of  the  sacroiliac  articulation.  The  application  of  the 
second  or  right  blade  is  more  difficult.     The  two  fingers  of  the 


188 


THE   SURGICAL   PROCEDURES 


left  hand  Avhich  serve  to  direct  the  blade  into  the  uteiiis,  are  also 
used  as  a  fulcrum,  and,  by  a  prying  movement,  the  blade  is 
urged  toward  the  symphysis,  to  a  position  opposite  its  fellow 
(Fig.  103).  The  two  halves  are  now  brought  together  and 
locked.  In  the  extraction  which  folloAvs,  anterior  rotation  of  the 
occiput  is  favored  by  giving  the  instrument  a  slight  impulse  in 


Fig.    103. — Forceps   applied   in   the   oblique   diameter   of   the   pelvis. 

that  direction  with  each  pull.  This  must  be  done  cautiously, 
imitating  in  a  way  the  spiral  movement  of  normal  internal  ro- 
tation. 

If,  in  the  attempt  to  apply  the  forceps  laterally,  one  should 
undesignedly  secure  a  sinciput  application,  the  extraction  is  con- 
tinued as  in  those  other  cases  in  which  efforts  to  slide  the  blade 
past  the  brow  fail. 


rORCEPS    OPERATIONS 


189 


Sometimes,  because  of  the  ease  with  which  the  blades  can  be 
locked,  one  may  be  misled  into  thinking  that  there  is  good  appo- 
sition when  there  is  not ;  and  occasionally  there  is  difficulty  in 


Fig.    104. — A  bad   application  of  the  forceps.     Much  pressure   in  this  position   would   prob- 
ably  result  in   facial   palsy ;    the   hold,   too,    is   very    insecure. 


getting  the  blades  to  lock  at  all  (Fig.  104),  or,  if  they  do  lock, 
to  remain  widely  separated. 


190 


THE   SURGICAL   PROCEDURES 


In  a  series  of  forceps  deliveries  the  oblique  application  will 
be  indicated  seven  or  eight  times  in  every  one  hundred  cases. 

IN  ABNORMAL  POSITIONS  OF  THE  HEAD 

Occipitoposterior  Positions. — It  is  the  rnle  rather  than  the  ex- 
ception that  a  posterior  position  vill  rotate  into  an  anterior  one 
v'hen  the  head  meets  Avith  the  pelvic  floor.     Eefnsing  to  assnme 


Fig.   105. — Forceps   delivery   in  the  occipitoposterior   position.      The  glabella  presses  firmly 
against  the  symphysis;:  the  occiput  rotates  over  the  perineum. 

this  more  favorable  adaptation  to  the  canal,  the  head  is  born 
with  the  face  anterior,  an  increase  of  abont  2  cm.  in  the  antero- 
posterior diameter.  The  increased  diameter  means  increased  strain 
on  the  perineum;  and,  since  frequent  disturbances  are  to  be  ob- 
served in  the  posterior  position,  even  in  spontaneous  births,  one 
may,  for  this  reason,  find  it  advisable  to  assist  nature  by  the  timely 
use  of  forceps. 

In  many  instances  it  will  be  found  that  as  the  head  is  being 
drawn  downward,  it  tends  to  rotate  into  an  anterior  position. 


FORCEPS   OPERATIONS 


191 


This  should  be  encouraged,  and,  as  soon  as  it  has  turned  far 
enough,  so  that  the  forceps  can  be  reapplied  in  the  oblique  di- 
ameter, further  rotation  may  be  accomplished  by  a  readjustment 
of  the  instrument.  In  case  the  head  will  not  rotate,  the  mechan- 
ism under  forceps  extraction  corresponds  to  that  of  spontaneous 
birth.     Traction  is  made  downward  and  backward  until  the  re- 


Pig.   106. ■ — Forceps  delivery  in  the  mentoanterior  position.     The  extended  neck  lies  under 
the  symphysis;   the  occiput  rotates  over  the  perineum.     The  head  is  greatly  elongated. 

gion  of  the  brow  appears  under  the  pubic  arch  (Fig.  105).  One 
then  pulls  upward  with  the  forceps,  the  wide  and  voluminous 
occiput  passing  over  the  perineum. 

Owing  to  the  less  favorable  adaptation  of  the  head  in  posterior 
positions,  and  the  greater  strain  put  upon  the  tissues  in  conse- 


192 


THE   SURGICAL   PROCEDURES 


queiice  thereof,  it  is  veiy  commonly  necessary,  in  order  to  save 
the  perineum  from  more  serious  injury  to  incise  the  vulvovaginal 
wall  laterally.     (See  Episiotomy,  pages  332  and  336.) 

In  a  thousand  posterior  positions  taken  from  literature,  the  for- 
ceps has  been  required  in  23.5  per  cent  of  the  cases. 

Face  Positions. — There  are  certain  conditions  when  forceps 
may  be  employed  to  advantage  in  face  presentation  positions, 


Fig.  107. — Forceps  delivery  in  presentation,  "by  the  brow.  Traction  is  made  down- 
ward until  the  superior  maxilla  has  passed  the  symphysis;  then  with  an  upward  curve 
the   occiput  is  swept   over  the  perineum.     Note  the   greatly   elongated   head. 


but  the  position  should  first  be  well  established  by  bimanual  ex- 
amination under  narcosis.  If  the  head  as  far  as  the  parietal 
eminences  has  entered  the  pelvis,  one  is  justified  in  making  the 
attempt  to  deliver ;  but  only  when  the  chin  is  directed  toward 
the  front,  is  the  operation  reasonably  easy.  In  applying  the 
blades  it  is  important  to  get  them  over  the  parietal  bosses  (Fig. 


FORCEPS    OPERATIONS  193 

106),  only  then  is  the  head  securely  grasped.  Traction  should  be 
made  strongly  downward  until  the  chin  passes  under  the  sym- 
physis. As  soon  as  this  point  is  reached,  the  forceps  is  elevated 
and  the  occiput  delivered  over  the  perineum. 

Whenever  the  head  is  found  deep  in  the  pelvis,  no  matter  what 
the  position,  one  is  justified  in  making  a  trial  application  of  the 
forceps.  If  the  head  lies  crosswise,  and,  surely,  if  it  occupies 
an  oblique  position,  the  possibility  of  rotating  the  chin  under 
the  pubes  is  not  remote.  The  hold,  however,  is  very  insecure 
and  dangerous,  since  one  of  the  blades  lies  over  the  point  of  the 
chin.  For  this  reason  the  use  of  forceps  in  face  positions  is  some- 
times not  practicable,  and  the  attempt  to  effect  delivery  with  it 
must  be  characterized  as  only  a  trial  measure.  After  making 
reasonable  effort  without  success  pubiotomy  or,  possibly,  cesarean 
section  comes  into  consideration,  if  the  child  is  alive.  If  the 
child  is  dead  perforation  and  cranioclasis  should  be  performed. 

Even  if  the  chin  lies  posteriorly,  an  exceptionally  rare  compli- 
cation, a  skillful  obstetrician  may  succeed  in  rotating  it  an- 
teriorly. The  technic  is  not  different  from  the  Scanzoni  method 
of  rotating  the  vertex,  but  it  is  more  difficult.  After  the  same 
manner  the  forceps  is  applied  obliquely,  and  the  face  brought 
into  a  transverse  position.  The  forceps  is  then  removed  and 
reapplied  in  the  other  obliquity,  and  rotation  completed.  While 
such  an  operation  is  possible,  it  would,  in  the  interest  of  the  child, 
be  better  to  perform  cesarean  section. 

Brow  Positions. — In  positions  of  the  brow  manifold  difficulties 
arise  because  of  the  greatly  increased  diameter  between  the  su- 
perior maxilla  and  the  occiput,  which  is  almost  as  great  as  the 
mentooccipital  diameter  (13.5  cm.)  and  fully  2  cm.  more  than 
that  of  the  pelvic  outlet  in  its  anteroposterior  diameter.  As  a 
consequence  the  head  becomes  fixed  in  the  pelvis,  and  calls  for 
operative  interference. 

To  insure  success,  the  head  must  be  well  down  in  the  pelvis 
and  the  nose  pointed  anteriorly,  or  at  least,  laterally  directed. 
Under  the  guidance  of  the  hand,  the  blades  of  the  forceps  are 
applied  in  the  transverse  diameter,  care  being  taken  that  the 
cephalic  curve  is  well  over  the  parietal  prominences  (Fig.  107). 
Traction  should  be  made  downward  until  the  region  of  the  su- 


194  THE   SURGICAL   PROCEDURES 

perior  maxilla  presses  under  tlie  symphysis,  Avhereupon  the  han- 
dles are  elevated  and  the  occiput  turned  out  over  the  perineum. 
The  operation  is  exceedingly  difficult  in  large  children.  Having 
failed  to  deliver  by  the  above  method,  one  may  attempt  to  bring 
the  face  still  deeper,  that  is,  low  enough  to  allow  the  chin  to  pass 
the  symphysis. 

HIGH  FORCEPS  DELIVERY 

"When  for  any  reason,  the  immediate  termination  of  labor  be- 
comes necessary,  the  child  living,  and  the  head  not  engaged,  the 
forceps  is  still  counted  a  serviceable  instrument.  And  when  it 
comes  to  a  choice  between  high  forceps  and  cesarean  section, 
the  former  operation  is  the  less  formidable  in  the  hands  of  the 
average  obst*.  rician.  The  experienced  surgeon,  however,  would 
perhaps  feel  safer  in  delivering  by  the  other  route;  but,  in  the 
emergency  of  general  practice,  forceps  is  preferable  to  the 
scalpel. 

If  one  decides  to  use  forceps,  he  must  again  consider  whether 
the  head  has  entered  the  pelvis  in  its  greatest  circumference,  or 
is  still  floating  above  the  superior  strait.  One  must  also  know 
with  reasonable  certainty  if  the  disproportion  between  the  head 
of  the  child  and  the  pelvis  of  the  mother  is  such  that  it  would 
be  dangerous  to  perform  the  operation.  Having  determined  its 
relative  safety,  the  obstetrician  proceeds  after  the  following 
manner: 

The  patient  is  placed  crosswise  on  the  bed  or  on  an  operating 
table  and  prepared  in  the  usual  way  for  a  surgical  procedure. 
She  should  be  deeply  narcotized,  and  the  hips  brought  to  the 
edge  of  the  table.  The  head  is  then  pressed  from  the  outside  as 
deeply  into  the  pelvis  as  it  will  go  (Hofmeier's  manipulation), 
and  the  forceps  introduced  in  the  usual  way,  except  that,  in  place 
of  two  fingers,  as  in  low  forceps,  it  will  be  necessary  to  use  all 
four,  or  even  the  whole  hand,  in  guiding  the  blades  high  enough 
to  make  sure  of  their  accurate  and  secure  application  (Fig.  108). 
It  is  sometimes  very  difficult,  after  both  blades  have  been  intro- 
duced, to  lock  them;  and  when  they  are  locked  the  handles  do  not 
come  closely  together,  because  of  the  wide  frontooccipital  di- 
ameter of  the  child's  head  which  is  embraced. 


FORCEPS    OPERATIONS 


195 


Before  proceeding  to  deliver,  the  operator  reassures  himself 
that  application  has  been  well  made.  He  does  this  by  making 
a  trial  traction.  With  one  hand  pulling  on  the  forceps  in  the 
usual  way,  the  fingers  of  the  other  hand  resting  against  the  head 


Fig.  108. — High  forceps  delivery.  The  head  occupies  a  transverse  position  at  the 
pelvic  brim,  and  the  blades  are  applied  in  this  position;  but,  in  order  to  guide  them 
into  place,  the  half  or  perhaps  the  whole  hand  will  have  to  be  introduced  into  the  vagina. 


of  the  child,  he  can  judge  if  the  blades  have  taken  a  firm  hold. 
If  they  have  not,  the  fingers  will  be  separated  from  the  advanc- 
ing part,  and  a  readjustment  of  the  blades  must  be  made. 

After  making  a  fair  test  in  this  way,  the  operator  crouches 


196  THE    SURGICAL   PROCEDURES 

ill  front  of  the  patient,  or  if  he  prefers,  sits  on  a  low  stool,  and 
takes  hold  of  the  forceps  from  below.  Traction  is  made  down- 
ward toward  the  floor.  ]Mnch  force  is  not  permissible,  yet  one 
can  not  hope  to  draw  an  object  like  the  head  throngh  a  constric- 
tion so  unyielding  as  the  pelvis  without  considerable  effort ; 
nevertheless,  the  procedure  must  not  be  a  tug  of  war. 

Where  a  little  more  room  is  needed,  an  expedient  of  some  value 
is  to  hang  the  woman  over  the  edge  of  the  table  in  the  Walcher 
position.  By  springing  the  pelvis  in  this  way  a  slight  increase 
is  gained  in  the  conjugate  diameter  (Fig.  7). 

Compression  of  the  child's  head  is  unavoidal)le;  therefore,  it 
becomes  necessary  after  each  effort  to  separate  the  handles  for  a 
few  moments  before  renewing  traction. 

If,  after  making  eight  or  ten  such  efforts,  the  head  can  not  be 
brought  down,  the  child  still  living,  other  means  of  delivery, 
such  as  pubiotomy,  version,  and  cesarean  section,  have  to  be 
considered.  If  the  child  has  succumbed,  it  may  very  properly 
be  delivered  by  the  cranioelast. 

In  bringing  the  head  doAvn  into  the  pelvis,  the  strait  is  passed 
in  its  transverse  diameter;  and  unless,  perchance,  the  head  turns 
within  the  blades,  the  forceps  should  be  taken  off  and  reapplied 
obliquely.  Such  a  fortunate  evolution  as  the  rotation  of  the  head 
between  the  blades  is  one  of  the  advantages  made  possible  by  the 
solid  blade  forceps  of  McLane. 

Opinions  differ  widely  concerning  the  claim  made  for  the  axis- 
traction  forceps.  One  well  known  obstetrician  says,  "I  use  this 
instrument  in  all  cases;  without  the  traction  rods  in  low  and  mid- 
and  with  them  in  high  forceps  operations."  Another  testifies 
that  in  actual  practice  where  he  has  applied  both  instruments  on 
the  same  case,  he  has  been  better  pleased  with  the  simple  Simp- 
son forceps,  and  he  seldom  uses  any  other.  My  own  convictions 
are  that  while  the  axis-traction  forceps  (Fig.  109)  possess  ad- 
vantages, the  Tucker-McLane  instrument  is  capable  of  accom- 
plishing all  that  should  be  expected  of  forceps.  In  this  I  am 
constantly  reminded  of  the  statement  made  long  ago  by  Bau- 
delocque  that  it  is  not  so  much  the  instrument  which  is  to  be 
looked  to,  as  the  hand  that  uses  it.     One  must  know  one's  tools 


FORCEPS   OPERATIONS  197 

thoroughly,    their   possibilities   as   well   as    their   limitations,    if 
one  would  do  good  work. 

By  means  of  the  axis-traction  device,  it  is  possible  in  the  high 
delivery  to  make  traction  nearly  at  a  right  angle  with  the  su- 
perior strait ;  and,  oAving  to  the  universal  bearing  of  its  articula- 
tions, the  Tarnier  instrument  can  be  used  in  any  position.  This, 
again,  is  counted  a  disadvantage  by  those  who  are  accustomed  to 


Fig.    10?. — Tarnier   axis-traction    forceps. 

the  more  positive  action  of  the  simple  forceps.     (Fig.  110.) 

The  manner  of  applying  the  blades  is  no  different  than  in  the 
plain  forceps.  After  articulating  the  blades  they  are  made  se- 
cure by  a  thumb  screw.  The  operator  frees  the  traction-rods 
from  the  pin  which  holds  them  in  place  upon  the  under  surface 
of  the  shank,  and  slips  the  movable  sleeve  of  the  traction-bar 
over  their  notched  ends.  The  complete  attachment  terminates  in 
a  bar,  which  may  be  grasped  by  one  or  both  hands. 


198 


THE   SURGICAL   PROCEDURES 


In  making  traction  with  the  Tarnier  forceps,  it  is  advised  that 
at  all  times  the  handle  be  held  horizontally,  no  matter  what  po- 


Fig.  110. — Delivery  with  the  axis-traction  forceps.  The  head  is  grasped  as  it  lies 
transversely  at  the  pelvic  inlet,  one  blade  over  the  face,  the  other  over  the  occiput. 
Traction  is   made   entirely   on   the  bar   and   in  the  direction   of  the   pelvic   axis. 


sition  the  blades  may  assume ;  also  that  the  traction-rods  be  kept 
close  to  the  under  surface  of  the  handles.  Whether  or  not  the  in- 
strument be  unlocked  and  removed  when  the  head  reaches  the 


FORCEPS    OPERATIONS  199 

perineum,  is  a  matter  of  choice.     Tarnier  himself  taught  that  it 
should  not  be  unlocked. 


SPECIAL  DIFFICULTIES  ARISING  IN  THE  USE  OF 
FORCEPS 

Under  certain  circumstances  the  introitus  may  be  so  contracted 
that  the  introduction  of  two  fingers,  not  to  mention  the  whole 
hand,  can  not  be  made  without  occasioning  pain.  In  such  cases 
it  is  not  wise  to  use  force  at  the  risk  of  lacerating  the  tissues, 
but,  instead,  the  opening  should  be  enlarged  by  a  vaginoperineal 
incision. 

In  trying  to  pass  the  blade  between  the  fingers  and  head  it  will 
sometimes  not  go  forward;  and,  if  forced,  it  may  make  a  false 
passage.    One  must,  therefore,  vary  the  course  of  its  introduction. 

In  the  event  of  an  arm  or  the  umbilical  cord  lying  low,  the 
introduction  of  the  blades  should  be  made  with  special  precau- 
tion in  order  that  only  the  head  and  no  part  of  the  arm  or  cord 
be  included  in  their  grasp. 

It  is  difficult  to  lock  the  blades  if  they  occupy  different  levels. 
In  such  cases  one  undertakes  through  strong  depression  of  the 
handles  to  bring  about  their  proper  union;  but  it  may  be  neces- 
sary to  take  them  out,  and  put  them  in  again  before  a  secure  ar- 
ticulation can  be  effected.  If  one  fears  that  the  forceps  may  have 
slipped,  traction  should  be  stopped  at  once,  and  the  instrument 
reapplied;  otherwise  grave  injury  to  the  child  and  serious  trauma 
to  the  mother  can  result. 

In  hopes  of  saving  the  perineum,  one  will  sometimes  remove 
the  forceps  from  the  head  too  soon,  before  the  parietal  bosses  have 
passed  the  ischial  tuberosities,  and  it  may  have  to  be  put  on 
again;  therefore  it  is  wise  to  make  sure  that  the  head  has  been 
brought  far  enough  down  to  be  held  without  such  aid. 

If  the  child  is  dead,  the  forceps  should  not  be  used;  but,  in- 
stead, the  head  should  be  perforated,  and  the  delivery  completed 
with  the  cranioclast. 

The  use  of  forceps  on  the  after-coming  head  is  recommended 
if  the  attempt  to  deliver  manually  fails.  Generally  speaking, 
though,  the  forceps  is  of  no  avail  when  the  head  can  not  be  de- 


200  THE    SURGICAL   PROCEDURES 

liver ed  with  the  hands.  The  chances  are  that  by  the  time  one  has 
demonstrated  the  fntility  of  manual  delivery  the  child  has  per- 
ished. Still,  one  is  justified  in  trying  the  forceps.  The  body  of 
the  child  is  held  above  the  symphysis  by  an  assistant,  the  opera- 
tor introducing  the  blades  laterally  to  the  sides  of  the  head 
through  the  guidance  of  two  or  more  fingers.  In  order  to  lock 
the  handles,  they  must  be  firmly  depressed.  The  line  of  traction 
is  first  backward  and  downward,  then  horizontally  forward,  and, 
finally,  upon  the  exposure  of  the  mouth,  slowly  upward. 

Although  the  obstetric  forceps  is  not  designed  to  be  used  on  the 
breech,  one  may  sometimes  venture  to  employ  it  if  application  is 
made  in  the  bisiliac  diameter  of  the  child's  pelvis.  Only  light 
traction  is  permissible,  and  much  pressure  on  the  handles  must 
be  guarded  against. 

PROGNOSIS  IN  FORCEPS  OPERATIONS 

The  prognosis  in  forceps  operations,  if  one  hold  himself  strictly 
to  the  indications  and  observe  the  preliminary  conditions,  is  good. 
The  chief  harm  to  the  mother  that  comes  from  its  use  is  through 
infection,  which  is  rare,  and  lacerations  of  the  soft  parts,  which 
should  not  be  greatly  increased.  Where  infection  is  already 
present,  the  invading  microorganisms  are  only  intravaginal  and 
not  intrauterine;  and  it  is  not  easy  for  the  germs  to  get  beyond 
the  cervix,  unless  they  are  carried  beyond  by  the  forceps  or  the 
fingers. 

In  562  cases  of  forceps  delivery  at  the  Koenigsberg  clinic,  the 
following  analysis  has  been  published: 

17  of  the  mothers  died  following  the  operation: 
11  from  eclampsia  and  its  sequences. 

2  from  lung  and  larynx  tuberculosis. 

1  from  nephritis  and  lung  infarct. 

1  from  rupture  of  the  uterus,  which  occurred  before  forceps. 

1  from  infection,  which  existed  before  forceps. 

1  from  infection  through  forceps,  due  to  perforation  of  the 
vaginal  connective  tissue. 

Charging  both  cases  of  infection  to  the  forceps,  there  was  a 
maternal  mortality  of  3.38  per  cent. 


FORCEPS    OPERATIONS  201 

As  regards  morbidity,  only  157  cases  were  observed  witli  ac- 
curacy.    Of  these — 

59  had  a  temperature  during  the  puerperium  above  38  degrees 

Centigrade,  or  37.6  per  cent. 
21  of  these  had  no  connection  with  the  forceps. 
34  of  the  others  had  a  very  slight  rise  of  temperature,  and 

this  lasted  but  a  short  time. 
4  had  severe  infection,  or  2.5  per  cent. 

Fetal  mortality:  Of  the  562  deliveries,  70  of  the  children  died, 
or  12.45  per  cent.  (Asphyxia  was  already  present  to  some  degree 
before  operation.) 

The  lacerations  of  the  mother  that  came  to  notice  Avere: 

11  of  the  uterus. 

1  of  the  vaginal   connective   tissue. 
4  of  milder  degree  of  the  vagina. 

39  incomplete  tears  of  the  perineum. 
4  complete  tears  of  the  perineum. 

4  of  the  clitoris. 

To  avoid  laceration: 

32  times  the  cervix  was  incised. 
139  times  the  vaginopeilneal  tissue  was   incised. 

Of  the  injuries  to  the  child  the  following  were  observed: 

40  had  some  degree  of  facial  paralysis. 

2  had  a  large  hematoma  of  the  cheek. 
1  had  a  large  hematoma  of  the  ear. 

1  had  a  large  hematoma  of  the  nose. 

1  had  a  subdural  hematoma. 

2  had  an  intracranial  hemorrhage. 

1  had  a  fracture  at  the  base  of  the  skull. 

Besides  these  injuries  there  were  two  with  fracture  of  the 
clavicle,  one  that  had  occurred  in  the  extraction  of  the  shoulder, 
one  from  artificial  respiration  after  delivery. 

Injuries  to  the  Mother. — The  forceps,  per  sc,  is  seldom  the 
cause  of  maternal  injury.  Forcibly  introduced  it  is  possible  to 
push  the  blades  through  the  vault  of  the  vagina,  or  even  through 
the  lower  uterine  segment;  but  with  reasonable  care  the  mere 
passage  of  the  instrument  is  unaccompanied  by  harm.  But  many 
more  injuries  come  with  the  extraction,  both  to  the  osseous  as 
well  as  the  soft  tissues.  The  higher  the  head  at  the  beginning  of 
extraction,  the  greater  will  be  the  injuries  sustained;  and  the 


202  THE   SURGICAL   PROCEDURES 

proportion  of  damage  bears  a  close  relation  to  speed.  The  liead 
is  not  only  increased  in  size  by  the  volnme  of  the  instrument, 
but  it  is  dragged  through  the  canal  in  a  comparatively  short  time 
and  without  undergoing  the  process  of  molding. 

The  probability  of  the  cervix  being  lacerated  is  increased  if 
the  forceps  be  applied  before  full  dilatation  has  taken  place. 
If,  as  sometimes  is  permitted,  instrumental  delivery  is  under- 
taken before  this,  one  must  proceed  with  great  care.  Should 
necessity  demand  haste,  there  are  other  and  better  ways  of  over- 
coming the  resistance  than  by  pulling  the  head  through  by  main 
strength. 

The  consideration  of  cervical  lacerations  is  taken  up  else- 
where, only  slight  reference  being  made  to  them  at  this  point. 
As  a  rule,  such  tears  are  lateral,  and  do  not  extend  into  the 
vaginal  wall ;  and  a  suture  is  demanded  only  when  there  is  se- 
vere hemorrhage.  If  the  cervix  has  been  badly  torn  in  a  pre- 
vious birth,  the  danger  of  its  tearing  again  is  increased,  even 
more  extensively  than  in  the  first  instance. 

All  the  soft  parts  are  particularly  exposed  to  laceration  when 
forceps  is  used  to  complete  delivery  after  pubiotomy  or  sym- 
physiotomy has  been  performed. 

Less  frequently  than  cervical  and  perineal  tears,  but  occurring 
often  enough  to  deserve  consideration,  are  the  injuries  to  the 
anterior  commissure.  The  most  fruitful  source  of  such  trauma 
is  the  too  early  elevation  of  the  handles.  Before  the  occiput  has 
passed  under  the  symphysis,  the  blades  are  pried  against  the 
pubic  bone,  and  the  tissues  cut  by  their  sharp  edges.  The  vas- 
cularity of  this  area  makes  it  necessary  when  lacerated  to  ligate 
the  dorsal  artery  of  the  clitoris. 

Extensive  and  serious  injuries  of  the  soft  parts  may  also  come 
from  the  blades  slipping  off  the  head,  the  operator  pulling  the 
locked  forceps  rapidly  through  the  birth  canal.  To  avoid  such 
an  accident  one  must  correctly  diagnose  the  position,  and  ac- 
curately apply  the  blades  before  making,  traction.  He  should 
also,  from  time  to  time,  investigate  and  note  whether  their  fixa- 
tion to  the  head  is  secure. 

The  osseous  structures  of  the  mother  also  may  suffer  injury. 
In  studying  the  dynamics  of  forceps  delivery  it  will  be  seen 
that  force  is  exerted  in  tAvo  directions,  one  against  the  pubes, 


FOKCEPS   OPERATIONS 


203 


the  other  along  the  pelvis  axis.  Thus  would  it  be  possible, 
in  making  traction,  to  rupture  the  symphysis,  if  force  enough 
were  applied.  The  sacroiliac  joint,  if  ankylosed,  can  be  broken 
in  the  same  way.  Fortunately,  such  accidents  are  rare  and  can 
hardly  occur  under  ordinary  circumstances. 


Fig.   111. — Hematoma  of  the   cheek,    due   to   injury   from    forceps. 


Injuries  to  the  Child. — As  already  pointed  out,  the  function 
of  the  forceps  is  chiefly  that  of  traction ;  but  while  performing 
this  office,  it  necessarily  becomes  an  instrument  of  pressure,  as 
well.     It  follows  then  that  the  greater  the  tractile  force,  the 


204  THE   SURGICAL   PROCEDURES 

greater  will  be  the  compression.  Bruises  and  contusions  of  the 
face  and  scalp,  severe  abrasions  of  the  epidermis,  deep  pressure 
marks,  ecchymoses,  and  even  hematomata,  are  common  (Fig. 
111).  If  the  pressure  of  the  blade  comes  over  the  stylomastoid 
foramen,  where  the  seventh  nerve  makes  its  exit,  a  one-sided 
palsy  of  the  face  commonly  results.  Still  more  serious  may  be 
the  pressure  on  the  skull  and  brain,  Avhereby  the  bones  may  be 
fractured  or  the  brain  compressed.  Also  in  pulling  the  head 
through  the  contracted  pelvis,  as  becomes  necessary  in  high 
forceps  delivery,  the  posterior  parietal  bone  may  suffer  an  abra- 
sion, or  even  become  depressed  as  it  passes  over  the  promontory 
of  the  sacrum.  The  occipital  bone  may  be  forced  loose  from  its 
articulations  with  the  temporal,  and  the  medulla  oblongata  pene- 
trated; the  temporal,  parietal,  and  frontal  bones  may  be  split, 
the  orbit  crushed,  and  the  base  of  the  skull  fractured.  It  is 
particularly  dangerous  if,  in  injuries  of  this  sort,  the  fracture 
extends  into  one  of  the  sinuses  of  the  brain.  The  symptoms  of 
such  a  lesion  are  like  those  of  simple  pressure;  but  the  prognosis 
is  made  much  vorse  by  the  hemorrhage. 

In  a  frontooecipital  application  of  the  forceps,  as  in  the  high 
operation,  one  must  be  extremely  cautious,  for  the  point  of  one 
blade  endangers  the  eye,  the  other  the  neck.  Injuries  so  serious 
as  the  enucleation  of  an  eye  and  the  paralysis  of  an  arm  (Erb's 
palsy)  have  followed  this  use  of  the  forceps.  Similarly,  the  tip 
of  the  blade  may  impinge  on  the  umbilical  cord  as  it  crosses  the 
neck,  causing  asphyxia  and  death  of  the  fetus.  So  simple  a 
procedure  as  the  withdrawal  of  a  blade  may,  if  one  be  incautious, 
tear  off  an  ear,  which  is  only  possible  if  the  blade  is  fenestrated. 

EXPRESSION  OF  FETUS 

Hardly  to  be  counted  an  operation,  although  a  definite  proce- 
dure, expression  of  fetus  is  deserving  of  more  than  passing  notice ; 
for,  of  all  the  artifieial  aids  to  delivery,  compression  of  the  ab- 
domen in  some  form  or  other  is  undoubtedly  the  most  primitive 
of  ancient  practices.  The  method  of  application  has  changed, 
but  the  principle  is  quite  the  same. 

After  the  method  of  Hofmeier,  the  head  is  made  to  engage 


FORCEPS    OPERATIONS  205 

in  the  milder  cases  of  pelvic  contraction  hy  means  of  external 
pressure.  After  overcoming  the  resistance  at  the  inlet,  birth  is 
allowed  to  go  on  spontaneously ;  but  it  may  be  ended  instru- 
mentally.  The  operation  does  not  contemplate  the  complete  ex- 
pression of  the  child.  The  procedure  is  simple,  but  to  be  ef- 
fective it  must  be  practiced  slowly  and  with  considerable  force. 
Standing  at  the  side  of  the  patient  toward  which  the  back  of 
the  child  is  turned,  the  operator  places  his  hand  on  the  fetal 
head  in  such  a  way  that  the  thumb  is  applied  to  the  occiput  and 
the  fingers  to  the  brow.  Strong  pressure  is  made  in  the  direc- 
tion of  the  sacrum,  the  object  being  to  force  the  head  into  en- 
gagement. Narcosis  is  essential  to  success,  and  the  trial  should 
be  undertaken  when  the  uterus  is  relaxed. 

Another  method  favors  the  transverse  engagement  of  the  head, 
and  simulates  somewhat  the  mechanism  of  the  high  forceps  de- 
livery. The  fingers  of  one  hand  are  applied  to  the  sinciput,  and 
those  of  the  other  to  the  occiput.  At  the  same  time  an  assistant 
presses  firmly  on  the  head  over  the  symphysis.  The  head  is 
thus  forced  in  the  direction  of  the  conjugata  vera  (Fritsch's 
method).  It  is  of  further  advantage  to  have  the  patient  in  the 
Walcher  position.  AVhether  the  attem]3t  has  succeeded  or  not 
can  generally  be  made  out  from  external  palpation  alone,  but 
should  be  verified  by  internal  examination.  For  fear  of  injur- 
ing the  lower  uterine  segment,  pressure  should  not  be  prolonged ; 
and,  of  course,  pelvic  contractions  of  a  high  degree  contraindi- 
cate  the  attempt  being  made  at  all.  One  should  also  take  into 
account  the  degree  of  molding  that  is  possible. 

It  is  well  to  remember  in  this  connection  that  before  carrying 
out  the  high  forceps  operation,  it  is  always  wise  first  to  try  to 
press  the  head  into  the  inlet  of  the  pelvis.  The  trial  not  only 
helps  one  to  estimate  the  amount  of  dystocia  to  be  overcome,  but 
the  impression  is  a  marked  aid  in  the  application  of  instruments. 

Extraction  of  the  breech  also  is  made  decidedly  easier  if  strong 
pressure  is  made  on  the  abdominal  wall,  for  not  only  is  the  ex- 
penditure of  tractile  force  thereby  lessened,  but  the  attitude  of 
the  child  is  preserved,  the  arms  remain  crossed  on  the  breast, 
and  the  chin  pressed  against  the  sternum.  While  the  obstetrician 
is  applying  the  various  maneuvers  of  extraction  per  vaginam, 


206 


THE    SURGICAL   PROCEDURES 


his  assistant  presses  upon  the  abdomen  with  the  outspread  hands, 
the  thumbs  on  the  anterior  surface,  the  tingers  covering  the  sides 
as  far  posteriorly  as  possible. 


Fig.   112. — Kristeller's   expression. 


Kristeller  recommends  a  procedure  whereby  in  head  positions 
the  supplemental  force  of  abdominal  pressure  may  be  used  in 
place  of  forceps.     The  indications  are  the  same.     The  operator 


FORCEPS   OPERATIONS  207 

stands  by  the  side  of  the  patient  facing  her  feet.  With  both  hands 
he  holds  the  fundus  of  the  uterus  in  such  a  way  that  his  thumbs 
lie  on  the  anterior  surface,  and  the  other  fingers  on  the  lateral 
walls  of  the  uterus.  Awaiting  a  contraction,  a  slow,  increasingly 
strong  pressure  is  exerted  until  the  pain  has  passed.  The  pro- 
cedure is  repeated  a  number  of  times,  generally  five  to  ten  being 
sufficient  (Fig.  112). 

The  advantages  of  the  operation  are  its  freedom  from  pos- 
sible infection  and  the  preservation  of  the  child's  posture.  Op- 
posed to  it,  stands  its  limited  utility.  Only  in  complete  dilata- 
tion and  a  yielding  disposition  of  the  soft  parts,  in  normal 
pelves  and  small  children, — in  short,  in  the  absence  of  resistance, 
can  one  reasonably  hope  to  succeed.  The  situation  which  offers 
the  best  chance  of  success  with  it  is  the  retardation  in  the  birth  of 
the  second  child  in  twins,  and  the  arrest  of  birth  in  a  multiparous 
woman  shortly  before  the  head  enters  the  superior  strait.  Nor 
is  the  procedure  free  from  danger:  the  placental  area  may  be- 
come compressed  and  the  fetal  circulation  disturbed ;  even  placen- 
tal detachment  has  been  known  to  occur.  It  is  therefore  essen- 
tial that  the  fetal-heart  sounds  be  observed  frequently,  and  that 
other  means  of  delivery  be  instituted  should  expression  be  ac- 
companied by  unfavorable  symptoms. 


CHAPTER  X 

PERFORATION  AND  CRANIOCLASIS 

Under  certain  circumstances  it  becomes  necessary  to  mutilate 
the  cliilcl  before  it  can  be  born  through  the  natural  passages. 
The  procedure,  always  a  shocking  one,  even  when  done  on  the 
dead  child,  becomes  horrible  when  performed  on  the  living. 
Thanks  to  modern  surgery,  the  occasions  are  rare  when  the 
child's  life  must  be  sacrificed  in  order  that  the  mother's  may  be 
saved.  When  it  becomes  evident  that  birth  can  not  be  completed 
by  any  of  the  other  measures  considered,  and  that  the  child  is 
dead,  or,  if  not  dead,  its  undelivered  state  threatening  to  the 
mother's  life,  it  becomes  necessary  that  something  be  done  to 
relieve  the  condition.  If  one  is  fully  satisfied  that  fetal  life 
is  extinct,  perforation  and  cranioclasis  should  be  instituted  at 
once  for  the  good  of  the  mother;  but  when  the  child  is  not  dead 
every  hopeful  measure  know^n  to  the  obstetric  art  should  be  care- 
fully considered  before  undertaking  so  fatal  a  procedure.  If 
the  life  of  one  or  the  other  must  be  lost,  the  child,  not  the  mother, 
should  be  the  one  sacrificed.  An  exception  might  be  made  in 
case  the  mother's  life  were  ebbing  away;  then  one  might  exert 
his  efforts  in  the  interests  of  the  child  alone.  In  an  emergency  the 
obstetrician  is  expected  to  do  the  thing  he  thinks  best  under 
the  circumstances,  no  matter  what  the  outcome.  And  while  the 
hospital  affords  better  facilities  than  the  home,  sometimes  he 
is  forced  to  undertake  grave  procedures  far  removed  from  hos- 
pital advantages.  Here,  again,  the  head  must  direct  the  hand. 
Better  lose  a  little  valuable  time  in  serious  contemplation  than 
do  the  wrong  thing.  A  panicky  obstetrician  plunges  into  many 
pitfalls. 

INDICATIONS  AND  CONDITIONS 

Only  rarely  does  the  size  and  hardness  of  the  normally  de- 
veloped head  become  an  indication  for  the  performance  of  per- 

208 


PERFORATION    AND    CRANIOCLASIS  209 

foration  and  cranioelasis,  but  Avhen  it  does,  the  indications  are 
the  same  as  in  contracted  pelvis.  In  those  rare  cases  of  faulty 
presentation,  when,  in  deep  fixation  of  the  face,  it  is  found  im- 
possible to  deliver  with  forceps,  perforation  becomes  necessary. 
Even  then,  if  the  child  is  alive,  cesarean  section  should  be  con- 
sidered. The  unfavorable  occipitoposterior  position,  likewise, 
may  sometimes  demand  the  same  treatment.  And  as  regards  the 
osseous  structures  of  the  mother,  various  kinds  of  obstruction, 
such  as  the  flat  pelvis,  the  funnel-shaped  pelvis,  exostoses,  and 
other  anomalies  make  the  pelvis  impassable,  except  the  child  be 
mutilated;  and  not  even  then,  if  the  pelvic  contractions  are  of 
the  absolute  degree.   (See  chapter  on  Cesarean  Section,  page  242). 

Other  obstacles  to  birth  may  present  themselves  in  the  form 
of  pathologic  changes  in  the  maternal  soft  parts.  Cervical  and 
vaginal  scars,  cicatrices,  and  tumors  can,  in  exceptional  eases, 
become  obstructive  enough  to  make  abdominal  section  the  only  alter- 
native.    (See  chapter  on  Birth  Complicated  by  Tumors,  page  402.) 

In  breech-births,  all  other  methods  of  delivery  failing,  the 
child's  head  must  be  perforated  and  compressed  before  it  can 
be  born.    Hydrocephalus  is  a  good  example  of  such  a  condition. 

Cranioelasis  is  indicated  in  all  cases  of  head  presentation  where 
perforation  has  been  performed  as  a  preparatory  measure.  It 
may  not  always  be  necessary  to  apply  the  cranioclast,  since  the 
perforation  itself  favors  reduction  in  the  size  of  the  head,  espe- 
cially when  the  disproportion  is  not  great  and  the  forces  of 
labor  are  strong.  In  practice,  however,  one  makes  use  of  the 
cranioclast  as  a  safe  means  of  expediting  delivery;  besides,  there 
is  a  remote  possibility  of  infection  when  delay  is  long.  If  any- 
thing were  to  be  gained  from  waiting  it  would  be  well  to  let  the 
birth  take  its  course;  but,  having  found  perforation  necessary 
in  the  first  place,  there  is  no  good  reason  why  the  child  should 
not  be  extracted  at  once,  if  the  mother  is  not  harmed  thereby. 
When  it  is  the  after-following  head  that  is  perforated,  the  body 
of  the  child  itself  furnishes  such  an  excellent  means  of  making 
traction  that  instruments  designed  for  this  purpose  are  of  no 
particular  advantage. 

In  order  to  carry  out  the  operation  of  craniotomy,  two  condi- 
tions must  be  fulfilled:  first,  the  os  uteri  must  be  sufficiently  di- 


210 


THE    SURGICAL   PROCEDURES 


latecl;  second,  the  pelvis  must  he  large  enougli  to  permit  the  head 
to  pass  after  it  has  been  performed.  With  regard  to  the  first  of 
these  requisites,  it  is  obvious  that  the  os  must  be  open  enough 
to  allow  the  guiding  fingers,  together  with  the  perforator,  to 


Fig.    113. — The  Xaegele  perforator. 


Fig.    114. — Smellie   perforator. 


reach  the  point  on  the  head  where  the  perforation  is  to  be  made ; 
therefore  an  aperture  smaller  than  a  silver  dollar  would  not  be 
large  enough  for  cranioclasis.  Should  there  be  any  need  of 
haste  the  cervix  must  first  be  opened  by  artificial  means. 


PERFORATION    AND    CRANTOCLASIS  211 

METHOD  OF  PROCEDURE 

Instruments,  Preparation,  Narcosis,  etc. — There  are  two  types 
of  instruments  used,  one  a  perforator,  the  other  a  trephine.  The 
perforator  is  essentially  a  spear-pointed  divulsor  with  a  cutting 
edge.  The  handles  of  the  Naegele  instrument  (Fig.  113)  are  con- 
nected by  a  jointed  bar  so  devised  that  the  instrument  locks, 
and  can  not  be  opened  without  first  releasing  the  catch ;  the 
Smellie  perforator  (Fig.  114)  has  no  lock.  The  other  instrument 
is  designed  to  cut  a  piece  out  of  the  skull  instead  of  being  forced 
through  it.  The  circular  end  that  does  the  cutting  is  guarded 
by  a  sleeve  of  metal  which  is  drawn  back  out  of  the  way  when 
the  process  of  cutting  is  begun.  By  a  twisting  movement  of  the 
wrist  a  section  of  bone  as  large  as  a  five-cent  piece  is  trephined 
away  (Fig.  115.) 

The  Braun  cranioclast  has  two  blades  that  cross  and  lock  like 
the  obstetric  forceps.  The  handles  also  are  constructed  after 
the  same  principle  (Fig.  116).  The  instrument  is  designed  to 
take  a  strong  hold  on  the  object  it  grasps.  To  secure  this  van- 
tage, it  is  fitted  with  a  threaded  bar  attached  to  the  handles  upon 
Avhich  travels  a  thumb  screw.  By  turning  this  screw  the  cranio- 
clast is  clamped  upon  the  fetal  tissues  as  tightly  as  may  be  de- 
sired. Both  blades  are  similarly  curved  so  that  they  come  to- 
gether securely,  the  internal  being  solid,  the  external  fenestrated, 
one  fitting  over  the  other.  The  three-blade  cranioclast  differs 
from  the  two-blade  in  that  the  extra  blade  stands  between  the 
other  two,  and  is  pointed,  more  like  a  perforator  (Fig.  117). 
Both  instruments  resemble  the  earlier  cephalotribe. 

The  specially  constructed  bone  forceps  of  the  Mesnard-Stein 
model  (Fig.  118)  is  curved,  has  alligator  jaws,  and  is  sometimes 
made  to  lock  when  closed.  The  instrument  of  Boer  (Fig.  119) 
is  straight,  the  biting  surface  of  the  blades  being  studded  with 
peg  teeth.    Both  instruments  are  strongly  made. 

The  instruments  to  be  sterilized  are  perforator,  cranioclast, 
bone  forceps,  scissors,  a  strong  metal  syringe  of  100  c.c.  capac- 
ity, and  an  irrigation  tube  (Fig.  120)  specially  designed  for  wash- 
ing out  the  brain  substance. 

Disinfection  of  the  patient  and  the  operator  should  be  thor- 
ough. 


212 


THE   SrRGICAL    PROCEDURES 


Fig.   lis. — Kiwisch-Martin    trephine 
with    obturator. 


Fig.   116. — Braun-Gessner    cranioclast. 


PERFORATION    AND    CRANIO  CLASIS 


213 


A  pail  of  Avater  is  kept  near  the  operator  in  which  to  plunge 
the  fetus  should  it  still  shoAV  signs  of  life  when  delivered.  It 
seems  almost  incredible  that  a  child  could  survive  perforation 


Fig.    117. — Tribladed  cranioclast. 


Fig 


118. — Mesnard-Stein    bone    forceps. 
Curved.,      Alligator    teeth. 


and  cranioclasis  even  for  a  brief  moment,  ]3ut,  unless  the  vital 
centers  at  the  base  of  the  brain  are  destroyed,  respiration  and 
circulation  may  continue  for  some  time. 


214 


THE    SURGICAL   PROCEDURES 


Narcosis  is  not  always  necessary  so  far  as  pain  is  concerned; 
bntj  on  the  grounds  of  liumanity,  it  is  desirable.  For  the  mother 
to  be  conscious  of  the  mutilation  taking  place  is  needlessly  shock- 
ing.    The  operator  should  make  a  final  and  careful  examination 


Fig.   119. — Mesnard-Stein    bone    forceps. 
Straight.      Peg   teeth. 


Fig.   120.— Irrigating   cannula. 


while  the  patient  is  under  the  anesthetic,  to  determine  beyond 
doubt  whether  the  child  is  alii^e. 

Perforation  of  the  Advancing-  Head. — If  the  head  is  not  al- 
ready fixed  in  the  pelvis,  it  should  be  securely  supported  at  the 
inlet  by  an  assistant.  Puncture  should  be  made  at  the  time  of  a 
contraction.     The  operator  sits  facing  the  patient  as  he  would 


PERFORATION   AND    CRANIOCLASIS 


215 


in  a  forceps  delivery.  The  closed  perforator  is  taken  in  the  right 
hand;  Avith  the  other  he  guides  the  point  of  the  instrument  along 
the  vaginal  canal  and  through  the  dilated  cervix  to  the  surface 


Fig.    121. — ^Perforating  the   advancing   head   with  the   Naegele  perforator. 


of  the  head  where  the  perforation  is  to  be  made   (Fig.   121). 
Placed  at  a  right  angle  to  the  scalp,  perferabl}^  over  a  suture  or 


216 


THE    SURGICAL   PROCEDURES 


a  fontanel,  the  perforator  is  forced,  into  the  cranial  cavity  up  to 
the  shoulder  on  its  blades,  the  locking  device  is  released,,  and 
the  blades  are  separated  by  squeezing  the  handles  together. 
This  done,  the  instrument  is  closed,  locked,  turned  quarter- 
round,  and  the  process  of  cutting  repeated;  afterward  it  is 
closed  and  cautiously  withdrawn.  If  neither  fontanel  nor  a 
suture    can   be    reached,    as,    for    example,    in   the   presentation 


Fig.   122. — Trephining   the    head   with    the   Kiwisch-Martin    trephine. 

of  a  parietal  bone,  the  instrument  is  placed  against  the  bone  and 
a  hole  drilled  through  it. 

The  trephine  serves  the  latter  purpose  better  than  the  perfora- 
tor. With  the  right  hand  the  center  rod,  or  obturator,  is  screwed 
into  the  head,  being  directed  to  the  place  of  entry  by  the  fingers 
of  the  left  hand  as  above  described.  The  trephine  portion  is  then 
slipped  over  the  obturator  until  it  meets  with  the  head  of  the 
child.  A  few  turns  are  sufficient  to  cut  through  the  bone,  a 
transfixed  button  of  Avhich  comes  away  with  the  instrument 
(Fig.  122). 


PERFORATION   AND    CRANIOCLASIS 


217 


Before  applying  the  cranioclast  it  is  essential  that  the  con- 
volutions be  broken  down,  and  their  substances  washed  out. 
This  is  done  with  a  metal  cannula  and  a  strong  syringe.  The  can- 
nula is  like  an  irrigating  tube,  one  end  having  a  bulb  point  with 
numerous  openings,  the  other  designed  to  receive  the  nozzle  of  the 
syringe.  The  tube  is  pushed  into  the  head  as  far  as  it  will  go,  the 
attempt  being  made  to  destroy  the  vital  centers  at  the  base ;  at  the 
same  time  the  contents  are  thoroughly  broken  up.  A  syringe  filled 
with  sterile  water  is  now  connected  with  it  and  forcibly  injected 


Fig.   123. — Forcing    water    into    the    trephined    head    througli    a    cannula    after    the    brain 
substance   has   first  been   broken  up   by   it. 

(Fig.  123).    This  is  repeated  several  times,  portions  of  the  brains 
coming  away  with  each  injection. 

To  penetrate  the  brain  through  the  brow  or  face  wdth  the 
Naegele  perforator  is  hardly  possible,  except  by  way  of  the  orbit 
or  between  the  frontal  bones.  The  former  is  the  easier  and  more 
accessible  route.  If  the  trephine  instead  of  the  perforator  is 
employed  in  this  region,  the  opening  is  best  made  through  the 
brow.  If  it  is  a  hydrocephalic  fetus,  a  simple  trocar,  or  even 
a  large  aspirating  needle,  may  answer  the  purpose  for  perfora- 


218 


THE   SURGICAL   PROCEDURES 


tion,  since  tlie  enlargement  of  the  head  is  due  to  fluid  rather  than 
to  brain  substance. 

Perforation  of  the  After- Coming  Head. — Perforation  of  the  aft- 


Fig.  124. — Perforation  of  tlie  after-coming  head  with  the  Naegele  perforator.  Down- 
ward traction  is  made  on  the  child's  'body  by  an  assistant.  The  perforator,  held  in  the 
right  hand  of  the  operator,  is  pushed  through  the  skin  in  an  upward  direction  at  the 
lower  border  of  the  sternomastoid  muscle. 


er-coming  head  is  a  much  more  difficult  procedure  than  the 
foregoing.  The  conditions  that  demand  the  operation  are  the 
same,  but  with  the  child's  bodj-  born  and  the  head  still  Avithin 


PERFORATION   AND    CRANIOCLASIS 


219 


the  pelvis,   usually  above   the   superior   strait,   entrance   to  the 
brain  becomes  exceedingly  difficult. 

The  most  favorable  point  for  perforation  is  through  the  fora- 
men magnum,  to  reach  which  one  proceeds  as  follows:  An  as- 
sistant makes  traction  doAvnward  on  the  body  of  the  child.  The 
operator  takes  the  perforator  in  the  right  hand,  and  carries  it 


oY  V-) 


u».>^= 


Fig.    125. — Dissection  of  the  neck,  showing  the  course  of  the  perforator.      (Hammerschlag.) 

to  the  posterior  border  of  the  sternomastoid  muscle.  Here, 
in  the  neighborhood  of  the  base  of  the  skull,  the  point  of  the 
instrument  is  forced  through  the  skin  and  musculature  to  the 
bone  (Fig.  124).  A  rather  free  opening  is  made.  With  the  in- 
dex finger  of  the  left  hand,  one  now  palpates  for  the  angle  be- 
tween the  vertebra  and  the  occiiDital  bone.  When  this  land- 
mark is  located,  the  point  of  the  perforator  is  made  to  cut  its 
wa;y  forward,  separating  the  atlas  from  the  skull,  and  opening 
a  passage  to  the  foramen  (Fig.  125). 


220 


THE   SURGICAL   PROCEDURES 


Extraction  of  the  Perforated  Head. — The  sequence  of  perfora- 
tion is  extraction;  and,  if  the  head  be  in  advance  of  the  body,  ex- 
traction may  best  be  accomplished  with  the  cranioclast.  The  fol- 
lowing is  the  method  of  employing  it: 

The  head  of  the  child  should  be  supported  by  an  assistant  if 
it  is  not  already  fixed  in  the  pelvis.  The  operator  takes  the  solid 
inner  blade  in  the  right  hand;  not  as  a  pen,  as  was  directed  in 
the  use  of  forceps,  but  as  a  fencing  foil.     Under  the  guidance 


Fig.  126. — Cranioclasis.  The  inner,  solid  blade  of  the  cranioclast  has  already  been 
passed  through  the  perforation  into  the  head,  and  is  being  supported  by  an  assistant. 
The  outer,  fenestrated  blade  is  being  applied   over  the  face. 

of  the  left  hand,  the  head  of  the  blade,  with  its  convexity  toAvard 
the  face  of  the  child,  is  shoved  into  the  opening  made  by  the 
perforator  or  trephine  as  far  as  it  will  go,  stopping  only  when  it 
reaches  the  base  of  the  skull.  This  half  of  the  instrument  is 
held  by  an  assistant  while  the  other  is  being  placed  in  position. 
The  head  need  not  noAv  be  so  firmly  pressed  upon  from  above 
(Fig.  126). 

To  introduce  the   second  blade,   the   operator  manipulates   it 


PERFORATION    AND    CRANIOCLASIS 


221 


into  position  much  as  he  would  the  second  blade  of  the  obstetric 
forceps,  and  the  handles  brought  together  and  locked,  one  blade 
inside  the  head,  the  other  outside   (Fig.  127).     They  hold  best 


Fig.    127. — Cranioclasis.      Seen    from    the    inside.      The    bladesi    have    been    locked    and    are 
now   being   clamped    together. 

when  fastened  over  the  face,  but  placed  at  the  back  or  sides  of 
the  head  they  are  competent  under  most  circumstances  to  bring 
away  the  fetus. 


222 


THE    SURGICATj   PROCEDURES 


111  the  first  position  of  the  vertex,  the  second  blade  is  locked 
from  above;  in  the  second,  from  below.  This  is  not  difficult 
since  the  cranioclast  has  no  pelvic  curve,  and  the  blades  may  be 
introduced   interchangeably.      The   point  to   be   borne   in   mind 


Fig.   128. — Cranioclasis.       The    compression    screw    to    its    maximum    has    been    tightened, 
firmly   fastening  the   cranioclast   to   the   child's   head. 


is,  that  the  concavity  of  the  second  blade  must  fit  over  the  con- 
vexity of  the  first,  whether  the  grasp  is  applied  to  the  occiput 
or  to  the  face.     It  is  slightly  more  difficult  to  lock  the  blades 


PERFORATION    AND    CRANIOCLASIS  223. 

from  below  than  from  above  since  one  must  depend  more  on  the 
sense  of  tonch. 

Proper  articulation  accomplished,  the  compression  screw  is 
affixed  to  the  handles  and  tightened.  (Fig.  128.)  Before  applying 
traction,  a  final  inspection  makes  sure  that  none  of  the  soft  parts 
of  the  mother  have  been  included  in  the  clamp  of  the  instrument. 

Delivery  is  essentially  the  same  as  a  forceps  extraction;  and, 
like  forceps,  traction  favors  rotation  generally  in  the  direction 


Fig.    129. — IJxtraction    with    the    cranioclast.      The    technic    is    essentially    tlie    same    as    in 

forceps    delivery. 

most  favorable  to  deliver3^  The  same  mechanical  principles  ap- 
ply. If  the  head  stands  at  the  brim  of  the  pelvis,  traction  is 
made  downward ;  if  it  lies  in  the  excavation,  one  pulls  hori- 
zontally; and  when  the  head  passes  over  the  perineum  the 
cranioclast  is  elevated  (Fig.  129). 

In  cases  of  more  marked  pelvic  contraction,  when  one  doubts 
the  possibility  of  extracting  the  head  Avith  the  two-bladed  cranio- 


224  THE   SURGICAL  PROCEDURES 

clast,  the  three-bladed  one  may  succeed.  Its  action,  as  already 
remarked,  is  more  like  the  cephalotribe.  The  technic  is  as  fol- 
lows: 

The  middle,  or  first  blade  is  held  in  the  right  hand,  and  is 
passed  up  to  the  point  on  the  head  where  puncture  is  to  be  made. 
With  a  boring  movement  it  is  made  to  enter  the  skull,  and  is 
forced  through  the  brain  to  its  base.  While  this  is  being  done, 
an  assistant,  as  in  all  such  procedures,  holds  the  head  securely 
from  the  outside  unless  it  is  already  fixed  in  the  pelvis.  The 
smaller  of  the  two  remaining  blades  is  now  applied  over  the 
occiput,  and  articulated  with  the  one  already  in  place.  The 
first  branch  of  the  instrument  has  no  identifying  points  of  con- 
struction by  which  the  position  it  occupies  within  the  head  can 
be  told.  To  avoid  such  confusion  the  handle  is  marked  with  a 
figure  on  its  anterior  surface,  which  indicates  the  direction  it 
should  take.  The  introduction  of  the  third,  or  last  blade  does 
not  differ  from  that  already  described,  the  concavity  of  the 
blade  fitting  over  the  sinciput.  Articulated  with  its  mate,  the 
compression  screw  is  moved  over  to  this  blade,  and  tightened 
enough  to  admit  of  all  three  locking.  The  force  accompanying 
the  manipulations  causes  a  free  discharge  of  brain  substance  with 
consequent  reduction  in  the  size  of  the  head. 

Extraction  of  a  perforated  head  that  lies  low  in  the  pelvis 
hardly  requires  the  use  of  the  cranioclast,  the  strong  bone  forceps 
of  Stein-Mesnard  being  quite  sufficient.  The  instrument  is  really 
a  cranioclast,  only  of  a  simpler  form,  and  is  manipulated  in 
much  the  same  way. 

Only  exceptionally  is  extraction  with  the  cranioclast  neces- 
sary in  breech-births.  After  the  head  has  been  punctured,  the 
Veit-Smellie  method  of  delivery  is  usually  easy  of  accomplish- 
ment, especially  if  aided  by  external  pressure.  Besides  helping 
expulsion  directly,  such  pressure  causes  the  discharge  of  brain 
substance,  and  indirectly  favors  extraction  from  reducing  the 
size  of  the  head.  This  method  will  fail  only  when  the  cranial 
bones  are  exceptionally  hard.  If  cranioclasis  is  necessary,  the 
inner  branch  of  the  instrument  is  pushed  through  the  foramen 
magnum,  and  the  outer  blade,  lying  against  the  occiput,  is 
clamped  over  it. 


PEEFORATION    AND    CRANIOCLASIS  225 

DIFFICULTIES  ATTENDING  PERFORATION  AND 
CRANIOCLASIS 

To  attempt  perforation  while  the  head  is  wabbling  about  in 
a  state  of  uncertainty,  would  be  dangerous,  as  well  as  futile ; 
the  head  must  first  be  immobilized.  Also  one  must  apply  the 
perforator  at  right  angles  to  the  surface  to  be  punctured.  Ob- 
liquely directed,  its  point  wanders  off  under  the  scalp,  and  may 
go  so  far  as  to  wound  the  mother.  There  are  few  difficulties, 
however,  to  be  met  with  in  operating  on  the  head  when  it  comes 
first,  as  compared  with  when  it  comes  last ;  for,  in  the  latter  sit- 
uation, before  the  perforation  can  be  made,  a  canal  must  be 
formed  between  the  outside  skin  and  the  point  of  entrance 
to  the  brain.  In  forcing  the  perforator  along  this  course,  it 
is  an  easy  matter  to  work  too  far  to  one  side,  and  reach  the 
mouth  or  stray  under  the  scalp  to  distant  points  on  the  oc- 
ciput. To  avoid  making  such  false  passages  one  must  first  lo- 
cate the  junction  of  the  vertebral  column  and  axis,  and  only 
at  that  place  should  the  perforator  be  introduced. 

Occasionally  in  a  labor  complicated  by  pelvic  contraction  and 
unyielding  soft  structures,  perforation  of  the  after-coming  head 
offers  special  difficulties,  and  attempts  to  puncture  may  fail 
because  of  inaccessibility.  It  then  becomes  necessary  to  make 
an  external  application  of  the  cranioclast ;  that  is,  the  inner,  or 
first  blade  is  forced  into  the  canal  made  in  the  soft  structures 
of  the  neck,  the  outer  one  covering  the  face.  In  this  way  a  small 
head  may  be  extracted.  If  this  fails,  the  body  will  have  to 
be  severed  from  the  head,  when  the  cranioclast  can  be  intro- 
duced through  the  foramen  magnum  or  through  a  perforation 
made  elsewhere  on  the  head. 

Very  much  oftener  one  experiences  trouble  in  cranioclasis  be- 
cause of  the  difficulties  accompanying  the  extraction  itself.  If 
the  blades  are  not  pushed  high  on  the  head,  and  only  a  part  of 
the  skull  is  held,  they  tear  out,  bringing  away  pieces  of  bone 
and  scalp.  This  becomes  very  easy  if  the  bones  are  loosely 
articulated.  For  example,  the  occipital  bone  can  more  eas- 
ily be  torn  out  than  the  bones  of  the  face.  In  a  macerated 
fetus,  too,  the  bones  become  so  loose  that  it  is  altogether  im- 


226  THE    SURGICAL   PROCEDURES 

possible  to  get  a  secure  hold  with  the  cranioclast;  and  every  time 
this  happens  the  insecurity  is  increased,  until,  finally,  it  becomes 
difficult  to  find  a  part  where  it  can  be  applied  at  all.  If  the 
edges  of  the  broken  bones  are  pointed  and  sharp,  it  is  Avell 
to  trim  them  off  with  bone  nippers,  for  otherwise  they  may 
cut  the  mother's  tissues. 

PROGNOSIS 

The  prognosis  in  perforation  and  cranioclasis  rests  upon  the 
possibility  of  infection  and  the  damage  from  maternal  trauma. 
As  far  as  infection  is  concerned,  it  is  no  more  likely  to  occur 
than  in  forceps  delivery,  if  the  operation  is  done  under  as  favora- 
ble circumstances;  but,  inasmuch  as  it  seldom  is,  the  procedure 
is  accompanied  by  a  much  higher  mortality.  When  done  wholly 
in  the  interests  of  the  mother,  it  is  generally  not  undertaken 
before  she  has  become  exhausted  and  perhaps  seriously  injured. 

As  for  trauma,  it  may  occur  from  perforation,  as  well  as  from 
extraction,  and  be  extensive  in  either  case.  The  perforator  may 
glance  off  the  head  and  puncture  the  uterine  wall;  or  it  may  be 
forced  in  a  wrong  direction.  Thus  may  the  bladder  be  opened 
and  a  vesicovaginal  fistula  result,  jagged  wounds  of  the  cervix 
be  inflicted,  and  numerous  and  varied  wounds  of  the  vagina 
caused,  all  through '  careless  manipulation  of  the  instrument. 
Such  a  thing  as  trephining  into  the  anterior  surface  of  the 
sacrum,  instead  of  into  the  child's  head,  has  been  done.  In 
cranioclasis,  lacerations  are  produced  in  various  ways:  the  moth- 
er's tissues  may  be  included  in  the  grasp  of  the  blades;  the 
instrument  may  slip  or  tear  loose ;  the  child  may  be  extracted 
too  rapidly  and  with  too  much  force;  and  the  birth  canal  may 
be  cut  into  by  the  jagged  ends  of  a  broken  bone. 

Out  of  232  cases  of  perforation  in  the  Vienna  clinic,  the  fol- 
lowing number  of  important  injuries  occurred: 

Complete  rupture  of  the  uterus  2  times 

Complete  rupture  of  the  perineum  1  time 

Lacerations  of  the  cervix  11  times 
Severe  lacerations  of  the  os  uteri  6  times 

Vesicovaginal  tistula  1  time 


PERFORATION    AND    CRANIOCLASIS  227 

Perforation  and  cranioclasis  are  procedures  which  may  be,  and 
oftentimes  are,  undertaken  by  the  general  practitioner.  They 
are  no  more  to  be  feared  than  a  difficult  forceps  delivery,  and  re- 
quire no  greater  skill. 


CHAPTER  XI 

EMBRYOTOMY 

111  dismembering  the  child's  body,  in  order  to  effect  a  de- 
livery, a  bisection  is  usually  sufficient.  If  this  division  is  made 
at  the  narrowest  part,  ■\vhicli  is  at  the  neck,  it  is  spoken  of  as 
decapitation;  if  the  body  is  severed  at  some  point  through  the  spinal 
colunui,  it  is  called  spondylotomij;  if,  instead  of  such  a  division, 
the  viscera  are  removed  to  reduce  the  bulk  of  the  fetal  ovoid, 
and  to  make  it  more  plastic,  the  procedure  is  referred  to  as  ex- 
enteration or  evisceration.  Other  multilating  operations  seldom 
demand  consideration. 

DECAPITATION 

The  severing  of  the  child's  head  from  its  body  is  indicated  (1) 
vrhen  the  fetus  becomes  fixed  in  a  transverse  position,  and  (2) 
when  mechanical  difficulties  make  further  mutilation  of  the  body 
necessary  after  decapitation  has  been  performed  and  before  the 
fetus  can  be  delivered. 

AVhen  it  is  found  impossible  to  convert  a  transverse  position 
into  a  more  favorable  one,  the  child  becomes  impacted,  the 
shoulder  and  its  adjacent  structures  are  forced  into  the  pelvis, 
and  an  arm  protrudes  from  the  vulva  (Fig.  130). 

A  marked  change  takes  place  coincidently  in  the  musculature 
of  the  uterus.  At  the  expense  of  the  lower  segment,  the  longi- 
tudinal fibers  are  drawn  upward  until  the  fundal  portion  gath- 
ers together  all  the  driving  powers  of  the  organ,  the  child,  after 
a  time,  coming  to  occupy  a  segment  that  has  neither  force  nor 
resistance,- — a  state  most  favorable  to  rupture.  It  is  in  such 
conditions  that  the  ring  of  Bandl  may  be  demonstrated,  its  con- 
stricting band  gripping  and  holding  fast  each  gain  in  the  strug- 
gle of  expulsion.  Accompanying  this  process,  certain  symptoms 
are  to  be  noted. 

228 


EMBRYOTOMY 


229 


Over  the  area  of  the  contraction  ring  the  abdomen  grows  ex- 
ceedingly sensitive,  the  patient  becomes  uneasy,  the  pnlse  small 
and  frequent,  and,  unless  something  is  done  to  relieve  the  situa- 
tion,— the  uterus  emi^tied, — rupture  takes  place,  and  the  child 
is  born  into  the  abdominal  cavity. 

Another  effect  of  impeded  birth  is,  that  the  nutrition  of  the 
fetus  becomes  seriously  interfered  with,  and  death  supervenes. 


Fig.   130. — Shoulder   presentation,   with  prolapse  of  the   arm.      Decapitation   was   necessary. 

In  the  absence  of  relief,  the  temperature  rises,  gas  accumulates 
in  the  cavity  of  the  uterus,  and  the  discharges  grow  foul.  Im- 
mediate delivery  is  indicated,  but  on  no  account  should  version 
be  undertaken.  Eupture  of  the  uterus  would  almost  certainly 
follow  the  attempt.  In  less  aggravated  cases,  the  child  being 
still  alive,  one  may,  Avith  great  caution,  attempt  to  turn  and  de- 


230  THE    SURGICAL   PROCEDURES 

liver ;  but,  even  then,  cesarean  section  might  Avell  he  considered. 

In  moderate  degrees  of  pelvic  contraction,  when  one  has  elected 
to  perforate  and  extract,  but  finds  it  difficult  even  then  to  de- 
liver, decapitation  becomes  necessary  in  order  to  carry  out  the 
further  procedures  of  dismemberment.  In  its  compressed  state, 
the  head  may  be  delivered  only  to  find  the  shoulders  caught  at 
the  superior  strait ;  or  the  head,  already  delivered,  will  so  in- 
terfere vith  the  manipulations  that  decapitation  must  be  done 
before  the  shoulder  can  be  reached.  Or,  perhaps,  the  child's 
body  itself,  through  distention  of  the  thorax  or  abdomen  with 
tumors  or  fluids,  may  l)e  so  large  that  further  mutilation  be- 
comes necessary  before  delivery  can  be  completed. 

Prelim.inary  Conditions. — Before  undertaking  so  serious  a  pro- 
cedure as  decapitation,  the  following  conditions  must  obtain: 

(1)  The  fetus  must  be  so  deeply  driven  that  the  advancing  part 
remains  fixed  within  the  superior  strait.  Only  when  this  is  the 
case  can  the  operation  be  carried  out  without  difficulty  and  with- 
out danger  to  the  mother.  An  attempt  to  decapitate  when  the 
child  lies  high  means  that  one  must  woi'k  far  up  within  the 
uterus  with  instruments,  and  experience  great  difficulty  in  locat- 
ing the  head.  Besides,  there  is  increased  danger  of  wounding 
the  mother.  Version  under  such  circumstances  would  better  be 
undertaken. 

(2)  The  pelvis  must  not  be  impassable.  A  conjugata  vera  of 
5.5  cm.  would  be  a  contraindication.  Cesarean  section  offers  the 
only  means  of  delivery. 

(3)  The  OS  uteri  must  admit  the  hand,  which  is  nearly  always 
possible,  since  embryotomy  is  seldom  undertaken  except  in  the 
expulsive  stage  of  labor,  when  this  requirement  has  been  ful- 
filled. Should,  however,  the  os  still  remain  undilated,  artificial 
methods  for  its  further  opening  must  be  employed. 

Instruments  Used.— The  key-hook  of  Braun  (Fig.  131).  This 
is  a  strong  metal  staff  with  an  acutely  bent  hook  at  one  end.  It 
is  provided  with  an  auger  handle  large  enough  to  be  grasped 
firmly,  and  strong  enough  to  stand  any  strain  the  hand  can  put 
upon  it.     The  instrument  is  about  34  cm.  long. 

A  pair   of  strong   scissors    (Fig.    132).     Any   strong   scissors 


embryoto:my 


231 


curved  on  the  flat  and  with  blunt  point  will  answer,  but  the 
Siebold  scissors  is  especially  designed  for  this  work. 

A  perforator,  Naegele  or  Smellie. 

Besides  the  above  instruments,  it  is  Avell  to  have  at  hand  a 
l)lunt  hook,  vaginal  retractors  and  speculum,  bone  forceps,  and 
an  abortion  forceps. 

The  usual  preparations  are  observed.     Narcosis  is  essential. 


Fig.    131.— Braun's   decapitation    hook.  Fig.    132.— Siebold's    decapitation   scissors. 

The  Technic  of  Decapitation 

Decapitation  can  best  be  done  with  the  Brauii  hook,  and  in 
the  following  manner: 

The  surgeon  takes  his  place  in  front  of  the  patient,  who 
lies    on    her    back    Avith    the    knees    drawn    up    and    separated. 


232  THE    SURGICAL   PROCEDURES 

A  sling  is  noosed  over  the  prolapsed  arm  of  tlie  baby,  and 
an  assistant  directed  to  make  strong  traction  downward  to- 
ward the  side  opposite  the  head.  The  operator  now  passes 
his  hand  into  the  vagina,  and  grasps  the  neck  with  the  in- 
dex and  middle  fingers  behind  and  the  thumb  in  front,  the 
other  two  fingers  lying  along  the  back.  Which  hand  is  the 
one  to  be  introduced  can  easily  be  determined  by  the  short 
rule,  that  it  is  the  opposite  one  to  the  hand  prolapsed.  Thus 
secured,  the  neck  is  drawn  down  with  one  hand,  while  with 
the  other  the  hook  is  passed  between  it  and  the  symphysis,  the 
inner  hand  directing  the  instrument  into  position  (Fig.  133). 
Upon  making  traction  the  vertebras  separate,  and  the  neck  comes 
down  into  the  vagina.  Then  begins  a  pulling  and  twisting  of  the 
instrument,  which  soon  tears  its  way  through  the  integument. 
The  tip  of  the  hook  should  always  be  directed  away  from  the 
birth  canal  toward  the  fetus  while  operating;  otherwise  much 
damage  may  be  done  the  mother's  parts.  With  the  fingers 
clamped  about  the  child's  neck  and  overriding  the  crotchet  of  the 
instruriient,  it  is  thus  possible  to  follow  the  progress  of  decapita- 
tion (Fig.  134).  As  the  vertebrae  break  and  the  ligaments  give 
way,  it  can  be  felt,  sometimes  heard.  Eight  or  ten  turns  of  the 
handle  generally  suffices  to  sever  the  head  from  the  body.  The 
decapitated  fetus  is  delivered  by  pulling  on  the  arm  which  al- 
ready protrudes  from  the  vagina  (Fig.  135).  Very  commonly 
the  head  remains  above  the  superior  strait,  and  must  be  im- 
mobilized by  an  assistant  before  any  attempt  is  made  to  deliver 
it.  Thus  fixed,  the  operator  passes  his  index  finger  into  the 
mouth,  hooks  the  thumb  over  the  separated  neck,  and  delivers, 
not  forgetting  the  value  of  external  pressure  as  an  adjunct  to 
traction  (Fig.  136). 

Instead  of  the  Braun  hook,  a  strong  pair  of  scissors,  like  the 
Siebold  shears,  may  be  used.  The  neck  of  the  child  is  grasped 
in  the  manner  described  above,  the  thumb  directing  the  cutting, 
and  by  a  series  of  small  bites,  severance  is  easily  accomplished. 
The  delivery  of  the  body  and  afterwards  of  the  head  is  as  above 
described.  For  the  general  practitioner,  the  hook  is  the  safer 
instrument  to  use,  since  with  the  scissors  he  can  more  easily 
wound  the  birth  canal. 


EMBRYOTOMY 


233 


Fig.    133. — Decapitation  with  the  Braun  hook.     Introducing  the  hook. 


Fig.  134. — Decapitation  with  the  Brauii  hook.  The  instrument  has  been  placed  about 
the  child's  neck.  By  giving  the  handle  a  twist,  first  to  one  side  and  then  to  the  other, 
the   neck,   after  a  few  such  movements,   becomes   separated  from   the   body. 


EMBRYOTOMY 


235 


Fig.   135. — Following   decapitation,    the    headless   trunk   of   the    child    is    delivered    by    nial'i 
ing  traction  on  the   protruding  arm. 


236 


THE   SURGICAL   PROCEDURES 


Decapitation  sometimes  becomes  necessary,  even  after  the  head 
has  been  delivered,  in  order  to  gain  access  to  the  fetus,  which 
must  be  further  mutilated  before  it  can  be  delivered.  The  op- 
eration is  easily  performed  Avith  scissors.  Before  the  headless 
trunk  can  be  extracted  it  may  be  necessary  first  to  take  off  one 
or  both  arms  of  the  child.     Not  succeeding  then,  it  may  be  com- 


Fig.  136. — Manual  extraction  of  the  decapitated  head.  With  the  index  finger  in  the 
child's  mouth  and  the  thumb  fixed  in  the  severed  neck,  which  furnishes  a  means  of  ap- 
plying traction,  the   operator's  other  hand  makes   pressure   over  the  fundus   of  the  uterus. 

pleted  by  placing  one  blade  of  the  cranioclast  in  the  thorax  of  the 
fetus,  the  other  over  its  back. 

In  a  prolonged  cross-birth  the  child  comes  to  occupy  a  posi- 
tion that  makes  it  exceedingly  difficult,  and  even  impossible, 
to  reach  the  neck.    The  breast  or  back  becomes  arched  forward, 


EMBRYOTOMY 


237 


Fig.  137. — !Evisceration.  The  impacted  fetus  lies  in  a  position  that  makes  the  breast 
easily  reached  with  the  perforator.  The  protruding  arm  is  drawn  strongly  downward  and 
outward. 


238  THE    SURGICAL   PROCEDURES 

bringing  the  head  and  neck  so  close  to  the  body  and  so  far 
above  the  reach  of  the  operator's  fingers  that  other  mutilating 
operations  must  take  place  before  the  uterus  can  be  emptied. 
The  consideration  of  such  procedures  follows. 

SPONDYLOTOMY 

When  the  back  becomes  the  most  dependent  part  of  the  child's 
body,  bisection  may  be  made  through  the  spine.  This,  too  is  best 
done  with  the  Siebold  scissors,  which  cuts  its  way  through  the 
viscera  after  having  first  severed  the  vertebral  column.  As  an 
independent  operation,  spond^^lotomy  will  seldom  be  employed; 
but  in  connection  with  evisceration  it  often  becomes  necessary. 

EXENTERATION 

Exenteration  or  evisceration  aims  to  give  flexibility  and  plas- 
ticity to  the  otherwise  unyielding  bulk  of  the  fetus.  In  carry- 
ing out  the  operation,  the  Naegele  perforator  is  driven  into  the 
child's  body  at  its  most  accessible  point;  the  instrument  opened, 
closed,  given  a  quarter-turn,  and  opened  again.  This  makes  an 
aperture  large  enough  to  admit  two  fingers  (Fig.  137).  Through 
this  opening  the  contents  of  the  cavity  are  pressed  to  one  side 
and  the  diaphragm  penetrated,  a  part  of  the  operation  which 
may  not  be  easy  of  accomplishment  without  first  removing  the 
intestines.  After  this  has  been  done,  the  spine  becomes  acces- 
sible and  its  resection  comparatively  easy.  The  collapsible  fetus 
is  delivered  manually;  or,  if  this  becomes  at  all  difficult,  the 
child  may  be  extracted  with  the  blunt  hook. 

ATYPICAL  CONDITIONS  AND  PROCEDURES 

The  different  forms  of  embryotomy  become  atypical  whenever 
an  abnormally  strong  development  of  a  single  part  of  the  child's 
body  occurs;  and  only  under  such  circumstances,  which  are  rare, 
will  it  be  found  necessary  to  depart  from  the  methods  described. 
Some  of  the  more  unusual  obstacles  that  may  arise  are  considered 
in  the  following  paragraphs. 

An  abnormal  width  of  the  shoulders,  so  that  delivery  in  the 


EMBRYOTOMY  239 

general  way  becomes  impossible,  may  require  the  use  of  the 
blunt  hook.  Failing  to  extract  with  this  instrument,  the  next 
thing  to  do  would  be  to  sever  both  clavicles,  allowing  the  shoul- 
ders to  fall  together. 

An  expanded  thorax  or  distended  abdomen,  such  as  might 
come  from  an  accumulation  of  fluid, — hydrothorax,  ascites,  tumors 
of  the  kidney,  distention  of  the  child's  bladder, — may  have  to 
be  evacuated  before  birth  can  take  place. 

When  there  are  tumors  to  deal  with,  like  the  outgrowths  in 
the  region  of  the  buttocks  and  neck,  their  removal  by  morcelle- 
ment  must  be  undertaken. 

Double  monsters  and  other  teratomata  sometimes  demand  every 
form  of  embryotomy  before  delivery  can  be  effected.  Twins,  too, 
occasionally  offer  similar  difficulties. 

Decapitation,  generally  a  simple  operation,  can  iDresent  great 
difficulties  if  the  neck  remains  so  high  that  it  can  not  be  reached 
with  the  fingers  and  hook.  Such  cases  are  not  well  suited  for 
embryotomy,  but  are  best  managed  by  version  and  extraction. 

In  dealing  with  a  macerated  fetus,  it  is  sometimes  difficult  to 
separate  the  neck  with  the  Braun  hook.  Scissors  will  be  re- 
quired because  of  the  leathery  character  of  the  integument. 

Another  difficulty,  the  fetal  posture,  may  be  such  that  neither 
fingers  nor  instruments  can  be  made  to  reach  the  neck ;  so  that, 
instead  of  a  decapitation,  a  spondylotomy  or  an  exenteration 
must  be  performed. 

While  the  decapitated  head  is  usually  brought  away  with  lit- 
tle difficulty,  it  can  cause  considerable  trouble  if  the  mother's 
parts  are  much  contracted.  And  should  one  find  himself  without 
a  cranioclast,  the  forceps  may  be  tried  and  as  much  pressure 
put  upon  the  blades  as  they  will  stand,  hoping  thereby  to  express 
the  brain  substance.  Another  expedient  worth  remembering 
when  other  measures  are  not  available  and  speedy  delivery  is 
not  essential,  is  the  application  of  moderate  traction  extending 
over  a  long  period — a  strong  claw  forceps  fastened  to  the 
scalp,  a  cord  attached,  and  a  Aveight  suspended.  Finding  this  too 
slow,  one  may  use  the  sharp  hook,  introduced  into  the  skull 
through  the  foramen  magnum,  taking  great  care  not  to  let  it 
slip  and  wound  the  mother. 


240  THE   SURGICAL   PROCEDURES 

The  prolapsed  cord  should  never  be  removed  in  undertaking 
any  of  the  operations  of  embryotomy;  it  does  not  interfere  with 
the  manipulations,  and  furnishes  a  serviceable  means  of  traction. 

In  performing  any  of  the  mutilating  operations,  there  must  be 
space  enough  at  the  introitus  to  allow  the  entire  hand  to  pass, 
even  if  the  vaginoperineal  tissues  have  to  be  incised  in  order 
to  obtain  it. 

PROGNOSIS 

The  prognosis  in  embryotomy  hinges  chiefly  on  the  possibility 
of  infection,  and  on  the  trauma  accompanying  the  various  opera- 
tions. The  procedures  themselves  are  not  dangerous,  but  in- 
asmuch as  they  are  never  undertaken  until  everything  else  has 
failed,  and  the  mother's  life  is  in  jeopardy,  the  outlook  from  this 
point  of  view  is  rather  bad.  Even  then  it  is  better  than  in  a 
difficult  version. 

I  will  give  one  illustrative  case: 

A  primigravida,  twenty-seven  years  of  age,  was  seen  in  consultation  on  the 
third  day  of  her  labor.  The  fetus  was  found  in  the  second  transverse  posi- 
tion ;  the  heart  sounds  were  best  heard  in  the  middle  line  between  the  umbilicus 
and  the  s^Tuphysis.  The  cervix  was  fully  effaced  and  the  sac  ruptured,  and 
the  right  shoulder  tirnily  fixed  in  the  pelvis.  The  mother 's  condition  was  fairly 
good  considering  the  length  of  her  ordeal. 

Under  narcosis  the  hand  was  passed  into  the  uterus;  but,  owing  to  the 
rigidity  of  the  introital  tissues,  this  was  accomplished  with  difficulty.  In  an 
attempt  to  secure  a  foot,  a  member  was  brought  down  which  proved  to  be  the 
arm  belonging  to  the  presenting  shoulder.  A  renewed  effort  to  reach  the  foot 
failed. 

A  third  physician  helped  to  estaljlish  the  belief  that  the  child  had  perished, 
that  the  lower  segment  of  the  uterus  was  greatly  thinned  out,  and  that  the 
contracting  ring  of  Bandl  stood  high  and  was  sharply  marked.  The  amniotic 
fluid  appeared  drained  off  to  the  last  drop,  and  the  uterus  itself  was  contracted. 

Under  still  deeper  narcosis,  version  was  undertaken,  but  was  soon  aban- 
doned because  the  hand  could  not  be  passed  beyond  the  constricting  ring.  It 
was  then  decided  to  do  a  decapitation.  This  also  failed.  The  shoulder  was 
so  deeply  wedged  in  the  pelvis  that  the  neck  could  not  be  reached  with  the 
fingers,  making  it  impossible  to  use  either  the  Braun  hook  or  the  Siebold  scis- 
sors.    An  effort  to  separate  the  spine  was  also  unavailing. 

The  patient  was  then  taken  to  St.  Paul  in  an  automobile,  the  distance  being 
more  than  seventy  miles.     But  she  died  before  reaching  the  city. 


EMBRYOTOMY  241 

A  necropsy  revealed  a  ruj)ture  of  the  uterus,  and  sepsis. 

Comment. — The  efforts  to  deliver  would  have  heen  carried  to  the  limit  had 
the  resisting  introitus  been  freely  incised.  This  would  have  given  room  to 
perform  exenteration,  which,  combined  with  spondylotomy,  might  have  effected 
a\delivery  of  a  mutilated  child  in  time  to  save  the  mother's  life. 


CHAPTEll  XII 

CESAREAN  SECTION 

Cesarean  section  is  an  operation  which  makes  it  possible  for 
the  pregnant  woman  at  or  near  term  to  be  delivered  through 
an  incision  made  in  the  uterus.  There  are  two  operations  des- 
ignated as  "cesarean,"  the  abdominal  and  the  vaginal,  but  only 
the  former  is  thought  of  when  discussing  the  subject  in  the  ab- 
stract. The  vaginal  section  is  a  modern  procedure  and  has  very 
different  indications  for  its  performance.  It  will  be  discussed 
under  its  own  caption. 

Historic. — For  many  centuries  cesarean  section  as  a  post- 
mortem operation  was  practiced  on  those  dying  late  in  preg- 
nancy. The  early  Romans  went  so  far  as  to  make  it  a  punisha- 
ble offense  to  bury  a  woman  with  her  child  undelivered.  Many 
instances  are  on  record  of  living  children  being  taken  from 
their  dead  mother's  body  in  this  way. 

The  first  successful  operation  to  be  performed  on  a  living 
woman  is  said  to  have  been  done  in  the  year  1500.  A  Swiss 
swine-gelder  by  the  name  of  Nufer,  who,  upon  the  failure  of 
numerous  midwives  and  several  barbers  to  deliver  his  wife,  seized 
the  instrument  most  familiar  to  his  hand,  and  opened  her  ab- 
domen. It  is  quite  unlikely  that  he  did  more  than  this,  for  we 
are  told  that  she  later  bore  him  five  other  children  in  the  usual 
way.  Tarnier  bears  witness  that  the  operation  had  not  been 
successfully  performed  in  Paris  during  his  time,  and  a  like  state- 
ment was  made  the  same  year  (1877)  by  Spaeth,  of  Vienna. 

In  1876-77  Porro,  of  Pavia,  reported  several  cases  success- 
fully delivered  by  abdominal  section;  but  his  operation  included 
the  removal  of  the  uterus,  as  well  as  the  fetus.  While  this  was 
a  step  forward,  the  great  stride  came  when  Saenger,  in  1882, 
published  his  method  of  suturing  the  uterus  and  leaving  it  in 
the  closed  abdomen.     His  operation  was  immediately  adopted, 

242 


Cesarean  section  243 

and   still   remains   the   classical   procedure   in   all   parts    of   the 
world. 

In  performing  adbominal  cesarean  section,  the  uterus  is  in- 
cised through  an  opening  made  in  the  abdominal  Avail,  and  the 
child  delivered  wholly  independent  of  the  birth  canal.  There 
are  several  indications  for  its  performance,  the  consideration  of 
which  follows. 

INDICATIONS 

The  Contracted  Pelvis. — The  subject  of  contracted  pelvis  as 
an  indication  for  cesarean  section  will  be  considered  from  two 
points  of  vieAv:  first,  as  an  absolute,  and,  second,  as  a  relative,  in- 
dication. In  the  one  case  the  contraction  of  the  pelvis  may  be 
so  great  that  delivery  of  a  normal  child  through  it  can  not  take 
place,  even  after  embryotomy  has  been  performed ;  in  the  other 
and  lesser  degree  of  contraction,  a  mutilated  child  might  so  be 
delivered. 

The  different  forms  of  contracted  pelvis  have  different  degrees 
of  passability,  the  slight  variations  depending  on  the  peculiar 
character  of  the  deformity.  Thus  a  flat  pelvis,  having  a  true 
conjugate  of  5.5  cm.,  would  be  absolutely  impassable,  while  the  sym- 
metrical generally  contracted  pelvis  would  be  equally  impassable,  al- 
though the  same  diameter  measured  half  a  centimeter  more.  Such 
distinctions,  however,  are  too  fine  to  be  really  practical.  The  sj^m- 
metrical  pelvis,  the  oblique  pelvis,  the  pelvis  contracted  by  the  pres- 
ence of  bony  tumors,  the  laterally  contracted  pelvis — ^in  short,  any 
pelvis  whose  configuration  reduces  one  of  its  diameters  to  the 
above  degree,  must  be  looked  upon  as  an  absolute  indication  for 
the  performance  of  abdominal  cesarean  section.  Of  the  osteo- 
malacic pelvis,  it  is  interesting  to  note  that,  while  seemingly  im- 
passable, it  may,  because  of  its  peculiar  plasticity,  yield  to  the 
forces  of  labor,  and  allow  the  child  to  pass.  The  funnel-shaped 
pelvis  and  the  kyphotic  pelvis  make  delivery  impossible  only 
when  the  distance  between  the  ischial  tuberosities  is  reduced  "to 
5.5  em.    (Compare  with  the  chapter  on  Pelvic  Contractions.) 

A  pelvis  whose  conjugata  vera  measures  5.5  cm.  to  7  cm.  pre- 
cludes the  birth  of  a  full-term  fetus  intact ;  it  does  not  prevent 


244  THE    SURGICAL   PROCEDURES 

its  delivery  in  mutilation.  Such  a  contraction  is  termed  a  rela- 
tive indication  for  cesarean  section.  If  one  has  to  deal  with  a 
pelvis  whose  true  conjugate  measures  7  cm.  or,  perhaps,  7.5  cm., 
and  it  is  evident  from  the  diagnosis,  as  well  as  from  the  history 
of  former  pregnancies,  that  natural  birth  can  not  tahe  place, 
cesarean  section  would  still  be  indicated  as  the  most  heliDful 
means  of  getting  a  live  child.  There  are,  however,  other  pro- 
cedures in  these  borderline  cases  which  have  been  practiced  with 
some  success,  namely,  pubiotomy,  symphyseotomy,  and  the  in- 
duction of  premature  labor. 

Anomalies  of  the  Soft  Parts. — In  like  degree  anomalies  of  the 
soft  parts  may  obstruct  the  birth  canal  and  make  delivery  by 
the  natural  route  quite  as  impossible  as  will  contractions  of  the 
bony  structures.  If,  for  example,  there  should  be  a  severe  scar 
formation  in  the  cervix  or  vagina,  particularly  the  superficial 
deformities  of  these  parts,  such  as  may  come  from  diphtheritic 
processes,  from  puerperal  inflammations,  and  from  certain  gyne- 
cologic operations,  vaginal  delivery  becomes  impracticable,  and 
abdominal  cesarean  section  furnishes  the  only  outlet.  (See  chap- 
ter on  Anomalies.) 

In  like  manner  the  canal  may  become  closed  by  new  formations. 
Carcinoma  of  the  vagina,  as  an  illustration,  may  completely  oc- 
clude it,  and  make  delivery  by  this  route  out  of  the  question. 
Growths,  benign  as  well  as  malign,  in  the  cervix  and  portio 
vaginalis  operate  in  the  same  way.  And,  furthermore,  it  is  pos- 
sible for  such  formations  to  obstruct  the  way  quite  as  effectu- 
ally by  protruding  themselves  into  the  pelvis,  though  they  may 
be  outgrowths  from  the  ovary,  rectum,  bladder,  or  of  the  outer 
wall  of  the  lower  segment  of  the  uterus.  (See  chapter  on  Genital 
Tumors.) 

In  rare  cases  the  topography  of  the  genital  canal  may  be  so 
altered  through  gynecologic  procedures,  such  as  ventral  fixation 
of  the  uterus,  that  cesarean  section  must  be  considered.  (See 
chapter  on  Anomalies.) 

Closed  and  Undilatable  Cervix. — This  would  be  an  indication 
only  when  conditions  demanded  immediate  delivery,  as  might 
obtain  in  eclampsia,  which,  coming  on  at  term  or  at  the  begin- 


CESAREAN    SECTION  245 

ning  of  labor,  requires  the  rapid  emptying  of  the  uterus.  Ce- 
sarean section,  under  these  circumstances,  is  one  of  the  recom- 
mended procedures.  The  abdominal  route  is  the  choice  of  many 
obstetricians,  but  more  recently  the  vaginal  section  is  well  thought 
of  and  may  be  undertaken  if  no  contraindication,  such  as  pelvic 
contraction,  exists.     (See  Vaginal  Cesarean  Section,  page  278.) 

Sudden  Death  of  the  Mother  Late  in  Pregnancy  or  at  the  Be- 
ginning- of  Labor;  the  Child  Living  and  Viable. — It  is  a  Avell- 
established  fact  that  a  pregnant  woman  dying  suddenly  in  labor 
or  near  the  end  of  pregnancy,  is  survived  by  her  unborn  child 
for  some  minutes.  The  more  acute  the  death,  the  longer  will  the 
unborn  child  live;  and,  conversely,  the  more  chronic  the  final 
illness,  the  earlier  will  it  perish,  perhaps  dying  before  the 
mother.  In  any  event,  if  the  mother  dies  with  the  child  alive 
in  the  uterus,  the  cesarean  section,  if  rapidly  performed,  may 
save  it. 

The  following  case  is  reported  by  Dr.  Alonzo  E.  Mack,  of 
Omaha : 

A  woman  in  her  fourth  pregnancy,  afflicted  with  varicosities  of  the  leg, 
was  to  be  confined  on  October  11.  On  the  morning  of  the  fourth,  her  Irusband 
telephoned  that  she  had  fainted,  requesting  the  physician's  immediate  pres- 
ence. Dr.  Mack  says,  '^  About  fifteen  minutes  later,  when  I  arrived  at  the 
house,  I  found  the  patient  dead.  Believing  that  not  more  than  three  to  five 
minutes  had  elapsed,  I  advised  the  immediate  opening  of  the  abdomen  and  the 
uterus.  Her  husband  gave  his  consent  and  without  waiting  time  to  listen  for 
fetal  heart  sounds,  and  knowing  positively  that  the  woman  was  dead,  I  incised 
the  abdomen  and  the  uterus  with  a  small  lance,  quickly  removed  the  child,  and 
clamped  and  divided  the  cord.  To  my  dismay  the  child  showed  no  signs  of  life. 
I  listened  with  the  stethoscope  for  heart  sounds,  but  heard  none;  the  baby  to 
all  appearances  was  dead.  In  hopes  there  might  be  life,  I  began  artificial 
respiration,  at  the  same  time  dipping  the  baby  alternately  in  hot  and  cold 
water.  I  also  used  the  Schultze  method  of  resuscitation.  For  forty  minutes 
these  measures  were  kept  up  without  the  slightest  indication  of  life.  It  then 
occurred  to  me  to  try  epinephrine,  but  after  filling  my  hypodermic  with  a 
1:1000  solution,  I  was  puzzled  to  knoAv  where  to  inject  it.  I  finally  introduced 
it  into  the  cord,  carrying  the  point  of  the  needle  well  through  the  abdominal 
wall.  In  about  two  minutes  tho  cord  began  to  beat,  and  the  pulsations  of  the 
heart  could  be  seen  and  felt.  Artificial  respiration  was  continued;  also  the  tub- 
bing. At  the  end  of  fifty  minutes  from  the  time  the  child  was  delivered,  it 
was  breathing  well,  and  crying  lustily.  Seven  months  later  the  baby  weighed 
nineteen  pounds.      (Jour.  Am.  Med.  Assn.,  Aug.  28,  1915.) 


246  THE   SURGICAL   PROCEDURES 

CONDITIONS 

Surgical  Ability. — Cesarean  section  is  a  laparotomy,  and  as 
sucli  demands  the  same  exacting  surgical  technic;  and,  since 
there  may  arise  in  the  course  of  the  procedure  complications  that 
call  for  skill  not  likely  to  be  possessed  by  other  than  a  com- 
petent obstetrician,  the  operation  should  be  performed  only  by 
one  Avho  has  had  surgical  training.  Only  ^vhen  there  is  im- 
mediate and  imperative  demand  for  the  operation  should  it 
be  undertaken  by  the  general  practitioner. 

Hospital  Facilities. — For  the  same  reason  cesarean  section 
should  be  performed  in  a  hospital,  for  only  there  can  the  prejDara- 
tion  of  instruments  and  dressings  be  .supervised  with  the  neces- 
sary degree  of  care;  and  in  the  hospital  the  light  is  good,  and 
ample  assistance  is  to  be  found.  So  that,  vhenever  a  hospital 
is  available,  the  patient  should  be  taken  there :  and  only  when 
the  exigencies  of  the  case  make  an  immediate  operation  impera- 
tive is  one  justified  in  performing  it  elsewhere. 

Birth  Canal. — In  opening  the  uterus  it  is  impossible  not  to 
spill  some  of  its  fluid  contents  into  the  abdomen,  and  should  the 
discharge  contain  harmful  microorganisms  there  is  danger,  not 
only  of  infecting  the  wound  itself,  but  of  causing  peritonitis. 
Obviously,  then,  it  is  essential  to  success  that  the  birth  canal 
be  as  free  as  possible  from  infection.  If  there  is  any  suspicion 
of  sepsis ;  if  the  sac  is  a  long  time  ruptured ;  if  the  pulse  has 
become  rapid  and  the  temperature  elevated,  the  cesarean  section 
as  a  relative  indication  should  not  be  undertaken. 

Viability  of  the  Child. — The  rule  that  the  child  must  be  alive 
and  viable  holds  good  only  when  cesarean  section  becomes  a 
relative  indication.  If  absolute,  there  is  no  alternative;  the  op- 
eration must  be  done,  even  if  the  child  be  dead,  since  no  other 
way  of  delivery  is  within  one's  power.  In  the  relative  indica- 
tion, the  child  being  dead,  perforation  and  cranioclasis  are  proper 
procedures.  Also  in  the  case  of  a  living  c-hild,  if  it  can  be  es- 
tablished beyond  a  reasonable  doubt  that  it  is  not  viable,  as, 
for  example,  in  hydrocephalus,  the  child  should  be  delivered  in 
this  way  rather  than  subject  the  mother  to  the  more  serious  risk 


CESAREAN    SECTION  247 

of  abdominal  section.  One  should  also  make  sure  that  he  is 
not  dealing  with  twins,  for  their  discovery  after  the  incision 
is  made,  reflects  discredit  on  the  diagnostic  skill  of  the  obstetri- 
cian, to  say  the  least.  The  following  instance  depicts  such  a 
case:  A  Avoman  with  a  moderate  degree  of  pelvic  contraction 
lost  her  first  three  babies  at  the  time  of  their  birth,  version  and 
extraction  being  performed  in  each  instance.  In  her  fourth 
pregnancy  it  was  decided  that  she  should  undergo  cesarean 
section.  Upon  opening  the  uterus  it  Avas  found  that  there  were 
two  children,  neither  of  Avhich  was  too  large  to  be  born  naturally. 

PREPARATION 

The  best  time  to  operate  is  after  labor  has  begun,  for,  un- 
doubtedly, there  is  an  advantage  in  the  natural  and  spontaneous 
onset  of  rhythmical  uterine  contraction.  And  more  than  this:  if 
labor  has  continued  for  some  time,  the  dilatation  effected  in  the 
cervix  favors  postoperative  drainage.  It  is,  however,  desirable 
to  have  the  sac  intact,  since  infection  is  then  less  likely  to  occur. 
In  case  it  has  ruptured  there  should  be  as  little  delay  as  pos- 
sible in  performing  the  operation. 

In  the  Hospital. — Just  preceding  the  operation,  the  pubes  and 
linea  alba  should  be  shaved,  and  the  skin  over  the  abdomen 
scrubbed  Avith  soap  and  water,  followed  first  by  alcohol  and  then 
by  a  sublimate  solution.  In  emergency,  the  scrubbing  may  be 
replaced  by  the  simpler  and  quicker  method  of  painting  the  sur- 
face with  a  ten  per  cent  tincture  of  iodine,  in  which  case  the 
skin  should  be  kept  dry. 

The  bladder  should  be  catheterized.  This  is  a  part  of  the 
preparation  often  overlooked  in  the  haste  and  excitement  in- 
cident to  the  operation. 

The  area  about  the  field  of  operation  should  be  protected  by 
sterile  towels,  or,  still  better,  by  the  laparotomy  sheet. 

The  operator  needs  three  assistants,  one  to  stand  at  the 
opposite  side  of  the  table,  another  to  make  pressure  over  the 
broad  ligaments  and  aid  in  the  fixation  of  the  uterus,  and  an- 
other to  handle   the  instruments.      One    other    skilled    person, 


248  THE   SURGICAL   PROCEDURES 

preferably  an  obstetrician,  is  reqnired  to  look  after  the  baby, 
performing  sucli  resnscitative  measures  as  may  be  indicated. 
And,  of  course,  there  is  the  anesthetist. 

The  instruments  are  few:  A  scalpel  or  two,  tissue  forceps,  ar- 
tery forceps,  two  fixation  forceps,  several  pairs  of  scissors 
(straight  and  curved),  abdominal  retractors,  needle-holder,  and 
needles.  The  fixation  forceps  referred  to  is  a  double  toothed 
vulsellum  for  grasping  the  incision  at  the  angle  of  the  wound  and 
upon  which  moderate  traction  is  made  while  the  first  few  stitches 
are  being  placed. 

For  suture  material,  ten-day  catgut  of  small  size  has  proved 
satisfactory;  but  there  is  no  objection  to  the  use  of  silk.  Indeed, 
some  surgeons  prefer  it,  and  condemn  absorbable  material.  Silk- 
worm-gut or  metal  clips  may  be  used  to  lu'ing  the  skin  together. 

The  instruments  are  boiled  for  at  least  five  minutes  in  a  soda 
solution,  and  then  conveniently  arranged  on  an  instrument  table. 

An  autoclave  drum  Avith  its  sterile  dressings  is  placed  within 
easy  reach  of  the  surgeon. 

It  goes  without  saying  that  the  operator  and  his  assistants 
should  be  thoroughly  sterilized,  properly  gOA^aied,  gloved,  and 
masked  (Fig.  138). 

For  the  use  of  the  one  whose  duty  it  is  to  look  after  the 
Ijaby  there  should  be  provided  tubs  of  hot  and  cold  water, 
a  pulmotor  or  lungmotor,  a  tracheal  catheter,  and  such  other  de- 
vices as  may  be  required,  in  case  of  necessity,  to  resuscitate  the 
baby. 

In  the  Home. — In  the  private  house  all  preparations  and  pro- 
cedures shoidd  be  as  near  like  the  foregoing  as  possible.  For  an 
operating  table,  the  table  found  in  every  kitchen  will  answer  the 
purpose.  This  is  covered  with  several  thicknesses  of  blanket 
over  which  is  laid  a  clean  sheet.  One  must  have  two  assistants 
in  order  to  undertake  the  operation  with  any  degree  of  safety, 
one  to  stand  opposite  the  operator,  the  other  to  administer  the 
anesthetic.  Before  beginning  the  operation,  a  dozen  or  more 
needles  should  be  threaded  so  that  no  time  need  be  lost  in  thread- 
ing and  reaching  for  them  after  the  operation  is  once  begun.  In 
case  one  does  not  have  with  him  sterile  towels,  dressings,  and 
sponges,  other  things  al)out  the  house,  such  as  handkerchiefs, 
diapers,  and  hand  toAvcls  must  be   borrowed  for  the   occasion. 


CESAREAN    SECTION 


249 


Fig.    138. — Surgeon    prepared    for    operation.      (DeLee.) 


250  THE   SURGICAL   PROCEDURES 

These  should  be  thoroughly  "svashed  aud  boiled  before  using. 
A  table  for  the  instruments  and  dressings  is  covered  with  a  clean 
sheet,  and  placed  within  easy  reach  of  the  operator.  Instead 
of  spreading  the  instruments  out  on  it,  it  is  better  to  keep  them 
in  a  solution  of  lysol  to  which  they  are  returned  from  time  to 
time  as  they  are  used.  After  painting  the  abdomen  with  a  ten 
per  cent  tincture  of  iodine,  the  field  of  operation  is  surrounded 
with  towels  wrung  out  of  lysol  solution. 

In  making  the  cesarean  section,  one  chooses  between  a  con- 
servative and  a  radical  operation.  The  one  contemplates  leaving 
the  uterus  capable  of  further  gestation,  the  other  leaves  the 
mother  unproductive. 

THE  CONSERVATIVE  OPERATIONS 

Corporeal  Hysterotomy. — An  incision  of  about  16  cm.  in  length 
is  made  in  the  median  line,  extending  as  far  above  as  below  the 
umbilicus.  (Fig.  139.)  The  integument  and  underlying  fat  are 
cut  through,  doAvn  to  and  onto  the  fascia.  All  bleeding  vessels 
are  clamped  and,  if  spurting,  ligated.  The  fascia  is  now  divided 
the  full  length  of  the  incision,  and  the  recti  muscles  exposed  and 
separated  by  blunt  dissection. 

Just  a  word  may  be  interpolated  here  concerning  the  ab- 
dominal wall,  which  has  undergone  considerable  change  during 
pregnancy.  At  term  it  is  much  attenuated,  the  fat  has  largely 
disappeared,  and  the  recti  muscles  are  often  separated.  So,  in  mak- 
ing the  incision,  the  scalpel  comes  down  upon  the  peritoneum  and 
uterus  surprisingly  quickly.  Xo  particular  harm  comes  from  en- 
tering the  peritoneal  cavity  thus  easily,  for  there  is  little  chance 
of  the  intestines  being  in  the  way ;  however,  it  is  recommended 
that  one  proceed  Avith  caution. 

A  fold  of  the  peritoneum  is  now  picked  up  on  each  side  with 
tissue  forceps,  and  nicked  open  with  the  scalpel.  The  index 
finger  is  then  introduced  into  the  opening,  and  swept  around  to 
make  sure  no  adhesions  are  present,  and  to  free  them,  if  there 
are  any.  Following  this  preliminary,  the  peritoneum  is  cut  the 
full  length  of  the  skin  incision  under  the  guidance  of  the  in- 
dex and  middle  fingers,  whereupon  the  deep  blue-red  uterus  lies 


CESAREAN    SECTION 


251 


exposed  to  view.  A  generous  piece  of  sterile  gauze,  rolled  for  con- 
venience in  handling,  is  wrung  out  of  hot  saline  solution  and  packed 
betw^een  the  abdomen  and  the  uterus  all  the  way  round.  This  at- 
tempts to  do  two  things :  dam  off  the  postperitoneal  cavity  and  hold 
back  the  intestines.  It  sometimes  does  neither.  An  assistant, 
Avith  the  hands  applied  to  the  abdomen,  can  make  pressure  quite 
as  effectively.    After  the  peritoneum  has  been  opened,  one  should 


Fig.    139. — Cesarean  section.      The   median   and   transverse   incisions. 


halt  long  enough  to  fasten  with  skin  clami^s  a  sterile  towel  over 
the  margin  of  the  wound  on  both  sides.  This  gives  greater  pro- 
tection to  the  abdominal  cavity. 

Up  to  this  point  the  surgeon  may  operate  with  considerable  de- 
liberation; but  the  next  few  steps  of  the  procedure  require  dex- 
terity, quick  perception,  and  cool  and  collected  judgment.  Af- 
ter the  knife  enters  the  tissues  of  the  uterus  there  is  no  time  to 


252  THE    SURGICAL    PROCEDURES 

stop  and  consider;  one  must  act,  and  act  quickly.  "Within  a  space 
of  time  less  than  one  minute  the  uterus  should  be  opened  and  the 
child  extracted. 

Beginning  at  the  fundus,  the  uterus  is  incised  in  its  midline 
dowmvard  for  a  distance  of  about  12  cm.  (Fig.  140).  While 
the  opening  should  be  made  rapidly,  it  must  not  be  made  so  vio- 
lently as  to  wound  the  child.  As  comi^ared  ^vith  the  resistance 
of  the  integument,  the  uterus  is  opened  with  one-half  the  force. 

If  the  placenta  has  a  lateral  attachment,  it  is  more  than  likely 
that  the  amnion  will  be  cut  through  at  some  point  inadvertently 
with  the  scalpel.  This  does  no  harm,  for  it  must  be  opened  any- 
vray.  AYhen  it  is  opened,  the  amniotic  fluid  wells  from  the 
opening  and  some  portion  of  the  fetus,  usually  the  thigh,  presents. 
the  incision  may  be  continued  with  the  knife,  but  the  scissors 
is  safer.  The  index  and  middle  fingers  are  passed  between  the 
child  and  the  membranes  as  a  guide,  and  the  full  12  cm.  laid 
open. 

If,  instead  of  the  amnion,  the  placenta  lies  beneath  the  in- 
cision, a  condition  that  is  much  more  troublesome  because  of  the 
increased  hemorrhage,  it  should  be  separated  from  the  uterine 
wall  with  the  fingers  until  the  free  border  is  reached,  from  which 
point  one  proceeds  as  above. 

After  the  child  has  been  lifted  out,  the  uterus  is  immediately 
grasped  with  both  hands,  and  held  firmly  until  the  cord  can  be 
clamped  and  severed.  Undue  haste  should  be  avoided,  since 
neither  mother  nor  child  is  in  much  danger.  Usually,  the  placenta 
detaches  itself  as  in  normal  birth;  but  in  case  it  does  not,  it 
must  be  loosened  manually.  Xo  attempt  is  made  to  stop  hemor- 
rhage altogether,  but  there  are  ways  of  holding  it  well  within 
the  bounds  of  safety.  One  therapeutic  measure  recommended  is 
the  use  of  pituitary  extract,  1  c.c.  of  which  is  injected  hypo- 
dermatically  just  preceding  the  initial  incision.  But  the  most  re- 
liable hemostasis  is  mechanical,  applied  by  an  assistant  who  holds 
the  broad  ligaments  with  the  hands,  or  compresses  them  through 
the  abdominal  wall. 

As  soon  as  the  placenta  has  lieen  delivered,  a  claw  forceps 
fixed  in  each  angle  of  the  wound,  and  held  securely  by  an  as- 
sistant, immobilizes  the  uterus,  effectually  closes  the  sinuses,  and 


CESAREAN    SECTION 


25J 


Fig.    140. — Topography   of   the    uterus   at    the    end    of   pregnancy.      Median    incision   shown. 


254 


THE    SURGICAL   PROCEDURES 


exposes  the  surfaces  to  be  sutured.  Coaptation  of  the  muscle 
wall  should  be  by  interrupted  rather  than  by  continuous  suture. 
It  takes  a  little  longer  to  do  it  this  way,  but  the  closure  is  more 
dependable.  Beginning  at  the  fundal  end  of  the  incision,  a  curved 
noncutting  needle  carrying  ten-day  catgut  of  small  size,  or,  if 
preferred,  silk  or  linen,  is  made  to  enter  just  beneath  the  serous 


Fig.    141. — Cesarean    section.      Interrupted    Cmuscular)    and    continuous    (serous)    suturin.s 

of  the  uterine  incision. 


surface.  As  much  muscle  as  may  be  encompassed  by  the  curve  of 
the  needle  is  included,  but  none  of  the  mucosa.  Coming  out  be- 
low the  mucous  meml)rane,  the  needle  is  reintroduced  at  a  cor- 
responding point  on  the  opposite  side,  a  similar  bite  of  the  mus- 
cularis  is  taken  and  the  needle  is  brought  out  just  under  the 
serosa  (Fig.  141).  Ten  or  twelve  such  stitches  will  be  needed. 
The  serous  margins  are  filially  brought  together  with  a  running 
suture  of  ten-dav  gut. 


CESAREAN    SECTION 


255 


After  closing  the  uterus  the  gauze  pack  is  removed,  the 
abdominal  cavity  flushed  with  saline  solution,  or  carefully 
sponged  out  with  gauze,  and  the  belly  closed.  Unavoidably, 
some  of  the  amniotic  fluid  and  blood  will  get  into  the  cavity, 
and,  since  it  is  impossible  to   get  it  all   out,   only  as  much  as 


Fig.   142. — Closing   the   abdominal    incision. 

can  be  removed  easily  and  without  manipulation  is  attempted. 
If  it  is  innocuous,  it  will  do  no  harm;  if  infectious,  peritonitis 
will  follow. 

The  usual  way  of  closing  the  abdomen  (Fig.  142)  in  layers 
is  to  bring  the  edges  of  the  peritoneum  together  with  a  running 
suture  of  catgut.     The  fascia  also  may  be  united  in  the  same 


!56 


THE    SURGICAL   PROCEDURES 


way;  but  a  series  of  interrupted  mattress  sutures  gives  greater 
security.     (Figs.  143  and  144.)     If  the  layer  of  fat  is  thick,  it, 


Fig.   143. — Overlaying   the   free   aponeurosis    of   one   side   with   that   of   the   other.      Method 
of  applying  the   mattress    suture.      (After  Judd.) 

too,  should  be  brought  together  before  closing  the  skin,  espe- 
cially if  the  subcutaneous  suture  or  the  Michel's  clip  (Fig.  145) 


CESAREAN    SECTION" 


257 


is  to  be  used ;  otherwise  the  thick  structures  between  the  fascia 
and  skin  tend  to  fall  apart.     The  wound  is  dressed  in  the  usual 


Fig.    144. — Approximating    the    peritoneal    surface    of    one    flap    to    the    aponeurosis    of    the 
other,  and  suturing  its  free  edge  thereto.      (After  Judd.) 

way, — a  light  dressing  held  in  place  by  a  binder  or  by  adhesive 
strips. 

Some  obstetricians  prefer  the  extraabdominal  to  the  intraab- 
dominal section  of  the  uterus.     Its  advantages  are  that  it  gives 


258 


THE    SURGICAL   PROCEDURES 


the  operator  a  wider  latitude  in  making  his  incision,  and  hemor- 
rhage can  better  be  controlled.  But  to  bring  the  pregnant  uterus 
outside  the  body  requires  a  much  greater  wound  in  the  abdomen, 
and  involves  fully  as  much  danger  of  infecting  the  peritoneum. 
Suprasymphyseal  Hysterotomy. — AVith  a  slight  upward  curve 
a  transverse  incision  about  15  cm.  long  is  made  just  above  the 
symphysis,  going  through  the  skin  and  superficial  fat  down  to 
the  aponeurosis  (Fig.  146).  Bleeding  arteries  are  clamped  and 
ligated.  The  fascia  is  then  opened,  and  separated  from  the  un- 
derlying muscle  for  several  inches  both  above  and  below  (Fig. 
147)  ;  and,  in  order  to  gain  a  better  view  of  the  field,  it  is  folded 


Fig.    145. — Applying  the  Michel  metal  clips. 

back  and  fastened ;  the  upper  leaf  with  a  single  stitch  to  the  skin 
below  the  umbilicus,  the  lower  to  the  integument  of  the  pubes. 
Obviously  this  is  but  temporary.  The  recti  muscles  now  are  sepa- 
rated in  the  middle  line,  and  pulled  to  the  side  with  retractors. 
This  exposes  the  peritoneum.      (Fig.  148.) 

At  a  point  al^out  one  inch  above  the  bladder,  the  peritoneum 
is  picked  up  Avith  pincettes,  and  divided  transversely  the 
full  length  of  the  wound.  The  retractors,  already  engaged  in 
holding  the  recti  muscles  apart,  are  made  to  include  the  divided 
peritoneum,  and  the  section  is  widely  opened.  The  uterus, 
which  now  shows  plainly,  is  incised  transversely,  going  only 
deep  enough  to  include  the  loosely  attached  serous  membrane. 


Fig.   146. — Transverse  alsdominal  incision.     Incising  the  fascial  layer. 


Fig.    147. — Transverse     abdominal     incision.       Blunt     separation     of     the     fascia     from     the 
underlying  muscle;    its   median   attachment   is   severed   with   scissors.      (After   Kronig.) 


260  THE   SURGICAL   PROCEDURES 

Tlie  upper  portion  of  this  divided  structure  is  carefully  de- 
tached from  the  "wall  of  the  uterus,  folded  back,  and  stitched 
to  the  margin  of  the  parietal  peritoneum  with  eight  or  ten  in- 
terrupted sutures  half  an  inch  or  so  apart.  This  practically 
shuts  off  the  peritoneal  cavity,  so  that  amniotic  fluid  and  blood 
have  little  chance  of  getting  in  when  the  uterus  is  opened. 
The  lower  portion  of  the  serosa  is  pushed  back  with  gauze  until 
the  whole  lower  segment  of  the  uterus  lies  uncovered  (Fig.  149). 

The  therapeutic  effect  of  pituitary  extract  should  not  be  lost 
sight  of.  Its  use  is  c[uite  as  important  in  this  operation  as  in 
the  other,  and  it  should  be  given  at  the  time  the  subserous  surface 
of  the  uterus  has  been  prepared  for  incision. 

Everything  in  readiness,  an  incision  10  to  12  cm.  long  is  made 
lengthwise  of  the  uterus.  (All  cutting  thus  far  has  been  in  a 
transverse  direction;  the  recti  muscles  were  separated,  not  cut.) 
If  an  extremity  presents,  it  is  grasped  and  the  child  extracted;  if 
the  head  presents,  its  expulsion  can  be  accomplished  by  lateral 
pressure.  The  delivery  of  the  placenta  differs  very  little  from 
that  of  natural  birth.  If  it  does  not  come  away  of  itself,  it  may 
be  expressed  or  removed  manually. 

In  closing  the  uterus,  the  divided  muscle  is  brought  together 
with  interrupted  catgut,  silk,  or  linen,  over  which  is  run  a  suture 
of  continuous  catgut.  The  reflected  serosa  is  then  freed  from 
the  parietal  peritoneum  to  which  it  was  fastened  when  the  space 
of  Eetzius  was  opened,  and  stitched  by  a  continuous  suture  to 
the  portion  below.  Then  follows  the  reuniting  of  the  parietal 
peritoneum,  the  fastening  together  of  the  recti  muscles,  the  sutur- 
ing of  the  fascia,  the  approximation  of  fat,  and,  finally,  the 
suturing  of  the  skin.     The  wound  is  dressed  with  a  light  binder. 

If  one  could  know  absolutely  that  the  contents  of  the  uterus 
were  innocuous,  one's  fears  of  peritoneal  infection  following  sec- 
tion would  be  greatly  allayed.  But  more  and  more,  as  experience 
ripens,  are  we  disinclined  to  chance  contamination  with  any  of 
its  fluids  or  discharges,  for  it  is  impossible  to  have  more  than  a 
reasonable  assurance  that  no  harmful  microorganisms  have  al- 
ready found  lodgment  therein.  Obstetricians  have  sought  to 
discover  a  way  by  which  the  uterus  can  be  opened  and  emptied 
abdominally,   without   invading   the    general   peritoneal   cavity; 


Fig  148. — Supi-asymphvseal  cesarean  section.  The  integument  and  fascia  have  been 
incised,  and  the  recti  muscles  retracted.  The  fascia  has  temporarily  been  sutured  to  the 
skin,  both  above  and  below.  The  parietal  peritoneum  is  exposed,  a  penline  showing  where 
it  is  to  be  opened.     Just  above  the  symphysis  can  be  seen  the  slightly  bulging  bladder. 


Fig.  149. — Suprasymphyseal  cesarean  section.  The  parietal  peritoneum  has  been  opened 
transversely;  the  uterine  peritoneum  has  been  incised,  and- separated  from  the  uterus. 
The  upper  margin  of  this  serous  layer  is  shown  v/ith  sutures  in  place,  uniting  it  to  the 
parietal  peritoneum.  The  interrupted  suture  is  shown  in  the  drawing,  but  a  continuous 
suture  may  be  used  if  preferred.  The  loose  peritoneum  below,  together  with  the:  bladder, 
is  pushed  toward  the  symphysis  and  away  from  the  uterus,  in  order  that  as  much  space 
as  possible  may  be  gained  for  the  incision  to  be  made  in  the  lower  segment  of  the  uterus. 
If  more  space  is  rec|uired,  the  bladder  may  be  separated  from  the  uterus  as  shown  in 
Fig.   ISO.      (After  Hammerschlag.) 


262 


THE    SURGICAL   PROCEDURES 


and,  while  the  so-called  extraperitoneal  cesarean  section,  to  be 
described  later,  theoretically  accomplishes  the  purpose,  it  seldom 
does  in  reality.  The  snprasymphyseal  hysterotomy,  while  not 
theoretically  extraperitoneal,  practically  is  as  far  as  the  opera- 


Fig.   150. — Transperitoneal    cervical    cesarean    section.       Separating    the    bladder    from    the 

uterus. 

tion,  per  se,  is  concerned.  But  it  does  not  remain  so ;  the  incision 
is  exposed  as  in  the  classical  section.  Doderlein  goes  a  step  fur- 
ther, and  opens  the  uterus  through  the  isthmus  of  the  cervix, 


CESAREAN    SECTION 


263 
A 


■which  is  aftei-Avards  covered  over  with  the  detached  bladder, 
short  description  of  his  operation  follows: 

Transperitoneal  Cervical  Section. — After  opening  the  abdomen 
either  by  median  or  transverse  incision,  the  vesicouterine  fold 


Fig.    151. — Opening  the   uterus. 


is  followed  down  to  its  attachment,  incised  at  its  junction  with 
the  uterus,  and  separated  from  the  isthmus  of  the  cervix  for 
nearly  its  whole  length  (Fig.  150).  The  separation  is  accom- 
plished 'p&vtly  by  sharp  and  partly  by  blunt  dissection,  care  be- 


264 


THE    SURGICAL   PROCEDURES 


ing  used  not  to  penetrate  the  bladder.  The  loosened  bladder 
is  then  retracted  toward  the  symphysis,  and  the  uterus  opened 
in  the  middle  line  through  the  denuded  isthmus.  The  section 
must  be  large  enough  to  permit  of  easy  delivery.     (Fig.  151.) 

If  the  child  presents  by  a  foot  or  the  breech,  it  is  extracted; 
if  by  the  head,  the  operator  locates  the  baby's  face,  and  with 


Fig.    152. — Bi-inging  the   child's    face    into    the    uterine    opening. 

his  finger  in  its  mouth  rotates  the  head  into  a  posterior  occipital 
position,  bringing  the  face  into  the  incision  (Fig.  152).  This 
accomplished,  an  assistant,  with  his  finger  replacing  that  of  the  op- 
erator, fixes  the  head  in  position  while  the  forceps  is  being  applied. 
In  introducing  the  blades,  the  right  is  passed  to  the  left  side  of  the 


CESAREAN    SECTION 


265 


face,  the  left  to  the  right,  that  is,  in  the  reverse  order  of  their 
vaginal  use.  This  brings  their  pelvic  curve  toward  the  symphysis 
(Fig.  153).  With  light  traction  the  head  is  readily  delivered,  and 
the  body  follows  without  difficulty.  Placental  delivery  is  even 
easier  than  in  normal  birth. 

Hemorrhage  is  controlled  by  suturing.     The  first  stitch  placed 


Fig.   153. — The    face    of   the    child   has   been    brought   into    the    opening,    and   is    held    there 
until   the   forceps   is   applied. 

at  the  upper  angle  of  the  wound  is  tied,  and  handed  to  au  as- 
sistant who  makes  sufficient  traction  on  it  to  fix  the  uterus.  In- 
cidentally, the  traction  closes  the  bleeding  vessels.  One  layer 
of  interrupted  sutures  (preferably  formalized  catgut),  followed 


266 


THE    SURGICAL   PROCEDURES 


by  a  running  suture  of  the  same  material,  effectual!}^  closes  the 
uterus  (Fig.  154).  The  bladder,  which  has  meanwhile  been  held 
out  of  the  way  with  a  retractor,  is  now  dropped  into  place  and 
sutured  to  the  uterus,  completely  overlying  the  cervical  wound 
and  isolating  it  from  the  peritoneal  cavity  (Fig.  155).  The  ma- 
terial for  uniting  the  bladder  wall  to  the  cervix  should  be  of  fine 
silk,  five  or  six  interrupted  sutures  of  which  are  employed.  The 
advantage  of  this  operation  over  the  classic  cesarean  section  is, 
that  the  uterine  wound  in  the  earlier  days  of  the  puerperium  is 
shut  ot¥  from  the  general  abdominal  cavity  by  the  imbricated 


Fig.    154. — Suturing  the  uterine  wound. 


bladder.  Since  serous  surfaces  become  quickly  adherent,  it  is 
likely  that,  as  far  as  exudates  from  the  uterus  are  concerned, 
there  is  now  little  danger.  Konig  reports  having  performed  the 
operation  sixteen  times  without  a  maternal  death. 

Extraperitoneal  Section. — Suprasymphyseal  cesarean  section 
with  a  few  modifications,  may  be  made  entirely  extraperitoneal. 
Up  to  the  point  of  opening  the  peritoneum  the  two  operations 
are  identical,  except  that  the  bladder,  instead  of  being  emptied, 
is  distended  with  fluid.     Through  the  pubovesical  space  of  Ret- 


CESAREAN    SECTION 


267 


ziiis  the  peritoneum  (unopened)  is  pushed  away  from  the  rectus 
muscle,  and  is  loosened  by  blunt  dissection  from  off  the  bladder. 
Working  toward  the  left  side,  the  vesicouterine  fold  of  perito- 
neum is  stripped  upward  from  the  lower  segment  of  the  uterus; 
and  the  bladder  and  detached  peritoneum  are  drawn  toward  the 
right  side  with  a  broad  retractor.  In  order  to  obtain  sufficient 
room  it  is  generally  necessary  to  sever  the  left  lateral  ligament 


Fig.  155. — The  detached  bladder  is  being  replaced  over  the  wound  in  the  uterus.  (The 
foregoing  series  of  pictures  illustrating  the  steps  of  the  transperitoneal  cervical  cesarean 
section   are    redrawn   from    Doderlein   and   Kronig's    Opevative    Gynecology.) 

of  the  bladder.  Through  this  exposure  the  uterus  is  opened  as 
in  the  suprasymphyseal  operation.  Delivery  and  repair  also  are 
the  same.     (Latzko.) 

The  extraperitoneal  operation  is  recommended  only  when  the 
lower  segment  of  the  uterus  has  become  much  attenuated  by  la- 
bor, the  patient  subjected  to  extensive  exploration  and  manipula- 
tion, and  the  amniotic  fluid  drained  away ;  and  not  then  if  actual 


268  THE    SURGICAL   PROCEDURES 

sepsis  is  present.  Should  there  be  sepsis,  the  uterus  may  be 
opened  and  drained  after  the  method  of  Rnbeska-Sellheim,  which 
is  one  of  provisional  fistnla.  The  abdomen  is  opened  above  the 
symphysis ;  and  the  parietal  peritoneum,  together  with  a  reflec- 
tion of  the  uterine  serosa,  is  seved  to  the  skin  margin.  The  union 
of  these  tissues  shuts  off  the  peritoneal  cavity,  leaving  only  the 
uterus  exposed  in  its  lover  portion,  vdiich  in  due  time  is  opened 
and  emptied.  Secondary  suturing  of  the  organ  and  abdominal 
wall  is  carried  out  later. 


THE  CONSERVATIVE  OPERATIONS  COMPARED 

Each  of  the  operations  described  has  its  advantages  and  its 
disadvantages,  and  comparison  may  not  be  amiss  at  this  point. 
The  classic  section,  or  corporeal  hysterotomy,  is  simple  and  eas^f 
to  perform ;  and  when  undertaken  in  an  emergencj",  it  is  likely 
to  turn  out  well.  In  cases  of  placenta  previa,  for  obvious  rea- 
sons, and  in  conditions  of  ventral  fixation,  because  of  disturbed 
relations  and  obscuration,  it  is  again  the  preferred  operation.  On 
the  other  hand  the  low  operation  is  less  likely  to  be  followed  by 
ventral  hernia.  There  also  is  less  hemorrhage  from  the  incision. 
Delivery  of  the  placenta  becomes  easy,  almost  physiologic;  and 
there  is  less  shock  and  less  danger  of  peritonitis. 

Offsetting  these  points  in  its  favor  is  the  fact  that  the  low  op- 
eration is  complicated,  and  requires  greater  skill  to  perform  it. 
It  is  also  charged  that  because  of  its  thin  wall,  a  scar  in  the  lower 
segment  is  more  likely  to  give  way  in  a  subsequent  pregnancy; 
however,  this  has  not  become  well-established. 

AFTER-CARE 

The  after-care  of  a  patient  delivered  by  cesarean  section  is 
that  folloAving  any  abdominal  operation,  plus  the  puerperium. 
She  should  lie  cpiietly  on  the  back  for  the  first  few  days.  She 
may  drink  freely  of  salt  water,  have  cracked  ice,  sips  of  iced 
tea,  and  such  things  as  are  not  likely  to  cause  retching.  It 
is  quite  usual  for  patients  to  suffer  from  tympanites,  and  the 
drug,  'par  excellence,  for  its  relief  is  pituitary  extract,  given  in 


CESAREAN    SECTION  269 

small  doses  three  or  four  times  daily  for  the  first  three  days. 
Ordinarilj^,  flatus  will  not  get  to  the  sphincter  ani  before  the  third 
day,  but  after  the  administration  of  pituitary  extract,  it  begins 
passing  much  earlier. 

On  the  third  day  the  bowels  should  be  opened  with  a  clyster 
or  a  tablespoonful  of  castor  oil,  preferably  given  in  the  morning 
before  eating.  After  the  bowels  have  been  opened,  the  nourish- 
ment may  gradually  be  increased  up  to  full  diet. 

The  skin  sutures  are  removed  after  seven  or  eight  days,  but 
the  wound  should  still  be  protected  and  supported  with  a  light 
dressing. 

Close  observation  should  be  made  of  the  lochial  discharge, 
noting  whether  it  be  normal  and  continuous.  If  disturbed,  it  may 
mean  that  it  is  being  forced  through  the  uterine  w^ound  into  the 
peritoneal  cavity.  Indeed,  it  is  not  improbable  that  much  of 
the  puerperal  morbidity  in  these  cases  comes  from  such  leakage. 

In  other  respects,  the  after-care  is  the  same  as  that  of  the 
normal  puerperium,  even  to  the  nursing  of  the  baby. 

THE  RADICAL  OPERATIONS 

Indications. — Where  infection  is  knoAvn,  or  strongly  suspected; 
where  there  is  complete  atresia  of  the  birth  canal,  so  that  free 
drainage  can  not  take  place;  in  conditions  of  osteomalacia,  a 
disease  said  to  be  cured  by  a  removal  of  the  ovaries;  in  the 
presence  of  carcinoma  and  multiple  myomata,  one  finds  indica- 
tions for  the  radical,  rather  than  the  conservative,  operation. 

Porro's  Operation. — The  preparations  and  first  steps  of  the 
Porro  operation  are  the  same  as  those  of  the  classic  section.  There 
are  two  ways  of  dealing  with  the  cervical  stump:  (a)  the  re- 
troperitoneal and  (b)   the  extraperitoneal. 

(a)  The  Eetroperitoneal  Treatment  of  the  Pedicle. — Since 
the  uterus  is  opened  only  after  it  has  been  delivered,  the  ab- 
dominal incision  must  necessarily  be  a  long  one.  The  organ  is 
turned  out,  the  peritoneal  cavity  protected  with  sterile  towels, 
and  the  uterus  incised  on  its  anterior  surface.  No  attempt  is 
made  to  remove  the  placenta.  If  it  comes  aw^ay  spontaneously, 
no  harm  is  done,  but  it  causes  less  trouble  if  it  be  left. 


270 


THE    SURGICAL   PROCEDURES 


Aside  from  the  gestational  alterations  in  and  aronnd  the 
uterus  that  have  to  be  taken  into  account,  the  steps  of  the  op- 
eration are  essentially  the  same  as  in  suprapubic  hysterectomy. 
Both  broad  ligaments,   together  with  the  Fallopian  tubes   and 


Fig.    156. — Supravaginal  amputation   of   tlie   uterus,   with   conservation   of   one   ovary. 

ovarian  vessels,  are  clamped,  tied,  and  severed;  the  round  liga- 
ments on  both  sides  are  similarly  tied  and  cut;  and,  finallv,  the 
uterus  is  amputated  (Fig.  156).  The  serous  membrane  of  the 
cervix,   unless   drainage   is   desired,   is   closed   above,     and    the 


CESAREAiST    SECTION 


271 


stump  made  retroperitoneal  by  first  suturing  the  severed  ends 
of  tlie  round  ligaments  and  tubes  together,  and  then  sewing  the 
peritoneum  over  the  entire  pedicle  (Fig.  157). 

(b)  The  Extraperitoneal  Treatment  of  the  Pedicle. — After 
opening  the  abdomen  in  the  median  line  and  turning  out  the  uterus, 
the  cervix  is  sutured  to  the  lower  angle  of  the  incision.  This 
somewhat  fixes  the  organ  and  at  the  same  time  partially  closes 
the  peritoneal  cavity.    With  sterile  towels  packed  about  the  wound, 


Fig.   157. — Closing   over   the   cervical   stump.      (After   Doderlein  and   Kronig.) 


especially  the  upper  part,  the  uterus  is  opened  and  the  child  ex- 
tracted. The  suturing  of  the  serosa  to  the  parietal  peritoneum  is 
then  continued  all  the  way  round,  and  the  abdominal  cavity  ef- 
fectually shut  off.  An  elastic  ligature  may  be  placed  about  the 
cervix  before  the  resection  is  made.  The  stump  is  cauterized,  the 
cervix  transfixed  with  a  strong  needle,  and  the  abdomen  closed. 
Recovery  from  the  operation  is  tedious,  and  the  tendency  to  hernia 
is  much  increased  by  the  fascial  defect. 

Total  Extirpation  of  the  Uterus. — The  abdominal  incision  in  this 


272  THE    SURGICAL   PROCEDURES 

case  is  carried  down  to  the  symphysis.  The  uterus  is  rolled  out, 
and  the  child  delivered  through  an  incision  in  the  uterus.  The 
ligaments,  as  in  the  retroperitoneal  treatment  of  the  pedicle,  are 
clamped  and  severed.  The  serous  membrane  of  the  uterus  and 
bladder  are  detached  from  these  structures  down  to  the  vagina. 
The  uterine  vessels  are  ligated  on  both  sides.  The  peritoneum 
on  the  posterior  cervical  wall  is  cut  across,  and  is  pushed  down- 
ward and  l^ackward  to  the  vaginal  wall.  AVertheim's  angular 
forceps,  one  applied  to  each  side  just  beyond  the  portio  vaginalis, 
are  now  affixed,  and  the  entire  uterus  is  resected.  Hemorrhage  is 
controlled  by  ligating  the  arteries  and  tamponing  the  veins.  The 
flap  of  the  bladder  peritoneum  in  front  and  the  fold  of  Douglas 
behind  are  sutured  to  the  margin  of  the  vagina,  and  this,  in  turn, 
is  covered  by  bringing  together  the  margins  of  the  broad  ligaments. 
Before  isolating  the  vaginal  opening,  it  is  recommended  that  drain- 
age be  left  protruding  into  the  canal,  which  may  be  removed  from 
below  on  the  third  day. 

Such  radical  procedures  are  not  to  be  considered  except  in  the 
presence  of  pyemic  infection  and  cancer,  the  former  sometimes 
presenting  a  condition  as  serious  as  the  latter,  and  even  more 
rapidly  fatal.  An  operation  carried  out  under  such  circum- 
stances, demands  exceptional  skill  and  judgment,  and  the  ob- 
servation of  most  exact  technic.  In  dealing  with  carcinoma,  a 
wider  extirpation  of  tissue  must  be  made,  including  the  para- 
metrium and  the  pelvic  lymphatics. 

SPECIAL  DIFFICULTIES  ENCOUNTERED  IN  THE 
PERFORMANCE  OF  CESAREAN  SECTION 

In  performing  cesarean  section,  accessibility  of  the  uterus,  de- 
livery of  the  child  and  placenta,  and,  later,  repairs  are  considera- 
bly interfered  with  if  the  patient  is  fat.  In  such  cases  it  is  neces- 
sary to  make  the  abdominal  incision  correspondingly  large. 

If  a  patient  has  already  undergone  a  laparotomy,  for  example, 
abdominal  cesarean  section,  it  is  well,  in  order  to  preserve  the 
anatomic  relations,  to  split  the  existing  scar. 

Considerable  importance  attends  the  adhesions  that  form  about 
the  abdominal  wound.  The  uterus  may  be  bound  down  by  them 
to  the  parietal  peritoneum,  as  well  as  to  the  intestines.     Patients 


CESAREAN    SECTION  273 

who  have  previously  undergone  the  operation  may  easily  acquire 
such  adhesions,  so  that  it  may  be  necessary,  before  incising  the 
uterus,  to  release  them  with  the  finger.  Also  in  the  hysterotomy 
itself,  one  may  choose  to  open  the  uterus  at  some  point  other  than 
where  it  was  opened  before.  Complete  agglutination  of  the  uterus 
to  the  abdominal  wall  has  been  known  to  occur.  Cesarean  sec- 
tion in  such  a  case  could  be  made  extraperitoneally,  an  advan- 
tage worthy  of  consideration. 

To  incise  the  uterus  over  the  placental  site  causes  increased 
hemorrhage ;  and,  in  order  to  avoid  such  a  complication,  the 
placenta  should  be  located  before  the  incision  is  made,  and  an- 
other point  selected.  If  one  inadvertently  cuts  into  the  placenta 
no  time  should  be  lost  in  temporizing ;  the  thing  to  do  is  to  go  on 
through  it  and  deliver  the  child. 

In  performing  the  suprapubic  section,  the  placenta  will  not 
normally  be  met  with ;  onl}--  in  placenta  previa  does  it  have  so 
low  an  attachment.  Here,  indeed,  would  be  a  complication  if, 
in  addition  to  the  abnormal  implantation,  the  area  of  attack  were 
bound  fast  to  the  belly  wall  by  a  previously  performed  ventral 
fixation  of  the  uterus.  Very  likely  the  procedure  would  have  to 
be  abandoned,  and  the  corporeal  operation  performed  instead. 

The  following  annotations  are  made  from  a  ease  reported  by 
Hammerschlag.  They  show  how  complicated  a  situation  can  be- 
come as  a  result  of  a  previous  surgical  procedure: 

Following  her  last  pi'egnancv  a  woman,  tliirty-two  years  of  age,  had  a 
vaginal  fixation  performed  for  j^rolapse  of  the  nterns.  Subsequently  she  be- 
came pregnant  and  went  to  term.  Upon  examination,  the  child  was  found 
lying  in  a  deviated  position,  the  vulva  and  vagina  contracted,  and  the  cervical 
opening  high  up  posterioily.  The  anterior  wall  of  the  uterus  was  fixed;  the 
posterior  wall  greatly  attenuated. 

Labor  began  with  rupture  of  the  amnion,  and,  as  the  process  went  on,  the 
cervix  was  drawn  still  higher,  so  that  finally  it  could  be  reached  only  by  intro- 
ducing the  entire  hand. 

When  the  os  uteri  had  opened  to  the  size  of  a  silver  dollar,  there  began  to 
show  signs  of  fetal  asijhyxiation,  failing  heart  sounds,  discharge  of  meconium, 
and  since  the  mother  was  extremely  desirous  to  have  a  living  child,  cesarean 
section  was  undertaken.  The  extraperitoneal  operation  was  chosen,  because 
of  the  early  rupture  of  the  sac  and  the  repeated  vaginal  examinations. 

The  abdomen  was  incised  transversely  above  the  symphysis ;  but  before  open- 
ing the  peritoneum,  the  bladder  was  found  so  adherent  to  the  anterior  wall 
of  the  uterus  that  delivery  through  the  cervix  was  found  impossible,  and  it 
became  necessary  to  open  the  peritoneum  at  a  higher  level. 


274  THE    SURGICAL   PROCEDURES 

The  uterus  was  so  twisted  upon  itself-  that  its  left  lateral  border  came  to 
the  median,  line  in  front.  The  vessels  were  enormously  developed,  some  of  the 
veins  in  the  broad  ligament  being  as  large  as  the  finger.  Delivery  was  made 
through  a  longitudinal  incision,  the  placenta  was  expressed,  and  the  uterus 
was  closed  in  tT\-o  layers. 

After  the  uterus  lias  l3eeiL  emptied  by  cesarean  section,  a  trou- 
blesome atony  sometimes  supervenes.  To  guard  against  such 
a  contingency,  pituitary  extract  or  ergot  should  be  given  shortly 
before  the  operation  is  begun. 

In  the  presence  of  hemorrhage,  the  uterus  remaining  large  and 
flaccid,  certain  other  measures  may  be  taken  to  bring  about  better 
tone  in  the  organ.  Direct  massage  of  the  uterus,  thermic  irritation, 
sterile  compresses,  tamponing  of  the  cavity,  are  all  helpful  in  the 
control  of  hemorrhage.  Placing  an  elastic  band  around  the  cer- 
vix may  check  the  bleeding  temporarily;  and,  in  the  suprapubic 
operation,  the  Momburg  tube  bound  about  the  vaist  may  be 
employed.  The  suprarenal  extract,  also,  has  proved  of  service  in 
controlling  hemorrhage.  A  syringeful  (1:10,000  solution)  is  in- 
jected into  the  uterine  wall.  If  all  efforts  to  stop  bleeding  fail, 
the  uterus  must  be  amputated. 

PROGNOSIS  AND  STATISTICS  IN  CESAREAN  SECTION 

The  prognosis  in  cesarean  section,  so  far  as  the  mother  is  con- 
cerned, depends  mainly  on  preliminary  conditions.  If  performed 
by  experienced  surgeons  and  under  favorable  circumstances,  the 
outcome  is  good;  but  bad  if  performed  by  the  general  practi- 
tioner and  in  the  patient's  home,  especially  if  repeated  examina- 
tions and  manipulations  have  been  made.  It  is  better,  therefore, 
if  the  woman  on  whom  it  is  thought  necessary  to  perform  such 
an  operation  be  taken  to  the  hospital  and  proper  arrangements 
made  before  she  has  been  exposed  to  infection  or  exhausted  by 
labor. 

Other  things  being  equal  the  radical  operation  is  accompanied 
by  more  serious  consequences  than  is  the  conservatiA^e.  But  very 
often  they  are  not  equal,  since  the  radical  operation  is  performed 
for  the  very  reason  that  the  case  is  already  complicated  by  in- 
fection. Out  of  456  classic  sections  performed  by  Oldhausen, 
Leopold,  and  Schauta,  30  deaths,  or  less  than  7  per  cent,  occurred. 


CESAEEAN    SECTION  275 

On  the  other  hand,  the  mortalitj^  in  radical  procedures  has  been 
between  16  and  23  per  cent. 

In  the  presence  of  infection  and  the  performance  of  a  radical 
operation,  it  is  still  possible  for  detached  portions  from  a  septic 
thrombns  to  find  their  way  through  the  circulation  to  more  dis- 
tant parts  of  the  body,  where  they  develop  into  metastatic  ab- 
scesses. 

If,  after  a  classic  section,  a  diffuse  peritonitis  occurs,  it  is 
necessary  that  the  abdomen  be  opened  and  drained;  and  should 
infection  follow  the  low  operation,  the  connective  tissue  overly- 
ing the  pubes  and  in  front  of  the  cervix  must  also  be  opened  and 
drained. 

Any  marked  lessening  of  the  flow  indicates  that,  instead  of 
passing  away  as  it  should,  the  lochia  is  being  retained  within  the 
uterus,  or,  possibly,  discharging  into  the  peritoneal  cavity,  and 
calls  for  investigation.  The  introduction  of  a  finger  is  generally 
sufficient  to  establish  the  patency  of  the  cervix,  although  a  drain- 
age tube  serves  the  purpose  better  inasmuch  as  it  keeps  the  canal 
open. 

The  Prognosis  for  the  Child. — This  is  particularly  good.  If 
living  when  the  operation  is  begun,  it  should  be  born  alive, 
though  it  is  not  uncommon  for  the  baby  to  be  born  in  apnea. 
This  comes  from  its  being  so  rapidly  removed  from  the  uterus 
that  the  usual  stimuli  of  parturition  are  lost;  and  the  blood  is 
still  so  rich  in  oxygen  that  excitation  of  the  respiratory  center  is 
delayed.  The  same  thing  is  to  be  observed  in  precipitate  labors. 
Generally,  the  child  begins  to  breathe  and  cry  in  a  few  moments. 
An  asphyxiated  condition  is  much  more  troublesome,  coming  as 
it  does  from  more  profound  influences;  and  for  this  reason  nar- 
cotics should  be  withheld  before  operating,  and  the  anesthesia 
should  be  as  brief  as  possible. 

Since  cesarean  section  is  oftenest  undertaken  in  the  interest  of 
the  mother,  the  outlook  for  the  baby  is  relatively  less  favorable, 
as  shown  by  the  following  comparison:  In  1,108  radical  opera- 
tions, there  was  a  fetal  mortality  of  22  per  cent ;  while  in  551  con- 
servative procedures  the  mortality  was  only  7.5  per  cent. 

A  woman  who  undergoes  cesarean  section  may,  unless  some- 
thing is  done  at  the  time  to  cause  her  sterility,  be  confronted 


276  THE    SURGICAL   PROCEDURES 

Avitli  tlie  same  operation  again.  And,  aside  from  the  dangers 
of  repeated  operations,  there  is  also  the  possihilitr  of  the  uterine 
sear  giving  aAvay  dnring  pregnancy.  This  is  not  a  eommon  cas- 
ualty, yet  eighteen  such  cases  were  reported  l)et'\veen  the  years 
1895  and  1910,  which  is  not  a  yery  great  risk,  considering  the 
large  numl^er  of  sections  performed.  It  is  probable,  however,  that 
a  later  report,  one  which  shall  include  more  suprapubic  sections, 
will  show  a  greater  proportion  than  this,  reasoning  that,  inas- 
much as  the  scar  is  located  in  a  zone  which  of  necessity  undergoes 
much  attenuation,  the  chances  of  rupture  will  thereby  be  increased. 

SECTION  PERFORMED  ON  THE  DEAD  OR  DYING 

Based  on  the  fact  that  the  unborn  child  may  continue  to  sur- 
vive for  a  short  time  after  its  mother's  death,  it  has  been  legally 
established  that  it  should  be  given  the  further  chance  of  living 
by  being  rapidly  delivered  through  the  abdomen.  In  some  coun- 
tries it  is  left  to  the  judgment  of  the  physician  as  to  whether  or 
not  this  shall  be  done.  If  no  signs  of  fetal  life  are  yet  remaining, 
he  may  decide  that  such  an  operation  is  uncalled  for.  In  other 
countries  a  physician  is  bound  to  perform  it  or  suffer  prosecution. 

If  at  the  time  of  death  the  parturient  canal  appears  to  be  suffi- 
cientl.v  dilated  to  permit  it,  the  fetus  may  be  delivered  with 
forceps,  or  turned  and  extracted.  If  this  does  not  appear  easy 
of  accomplishment,  cesarean  section  should  be  performed. 
Twenty  to  twenty-five  minutes  is  about  the  limit  the  fetus  can 
survive  after  the  mother  dies.  If  positive  signs  of  fetal  life, 
such  as  heart-beat  and  movement,  can  be  demonstrated,  the  in- 
dication for  delivery,  either  by  section  or  accouchement  force, 
is  positive.  Yet,  on  the  other  hand,  if  no  such  signs  are  to  be 
made  out,  and  there  is  still  reason  to  believe  the  child  may  be 
alive,  one  is  justified  in  urging  upon  the  family  the  reasona- 
bleness of  trying  to  save  it.  Nor  should  valuable  time  be  lost 
in  trying  to  prove  that  the  child  is  or  is  not  alive:  it  may  be  in 
asphyxia  and  yet  be  resuscitated.  (See  Dr.  Mack's  case,  page 
245).  To  attempt  to  save  a  fetus  so  immature  that  it  could 
not  survive  under  any  circumstances  would,  of  course,  be  ill 
advised. 


CESAREAN    SECTION  277 

The  operation  itself  is  nothing  more  than  a  cautious  opening 
of  the  abdomen  and  uterus,  and  the  simple  closure  of  the  ab- 
dominal wall  with  a  running  suture. 

Attempts  to  resuscitate  the  child  should  not  be  abandoned 
under  an  hour. 

About  50  j)er  cent  of  the  children  so  delivered  live. 

Under  some  circumstances  a  physician  is  justified  in  making 
the  section  on  a  woman  not  yet  dead,  but  in  a  dying  condition. 
It  should  not  be  done,  however,  without  a  consultation  of  phy- 
sicians and  agreement  that  the  mother  is  beyond  recovery  and 
that  the  child  is  living.  The  same  technic  should  be  followed 
that  is  observed  when  operating  under  more  hopeful  condi- 
tions. 


CHAPTER  XIII 
VAGINAL  CESAREAN  SECTION 

INDICATIONS 

Vaginal  hysterotomy,  or,  as  this  operation  may  properly  be 
called,  colpohysterotomy,  is  a  formidable  procednre,  and  is  un- 
dertaken only  npon  certain  T^'ell-defined  conditions. 

Complications  Developing-  in  the  Pregnant  State'  Which  Make 
Immediate  Delivery  Necessary. — Under  this  head  should  be  men- 
tioned, first  of  all,  eclampsia;  more  rarely,  premature  separation 
of  the  normally  located  placenta,  placenta  previa,  and  certain 
internal  diseases,  particularly  the  more  serious  affections  of  the 
lieartj  lungs,  and  kidneys. 

Stenosis  of  the  Cervix,  Which,  in  the  Process  of  Labor,  Pre- 
sents an  Effectual  Bar  to  Natural  Birth. — In  this  category  be- 
long tumors,  especially  myomata,  developing  in  the  cervical 
wall  or  on  the  portio  vaginalis;  also  cicatricial  changes,  either 
inherent  or  acquired. 

Asphyxia  of  the  Child  Early  in  Labor. 

APPLICABILITY 

Though  carried  out  after  the  most  approved  methods,  va- 
ginal cesarean  section  is  governed  by  usages  vhicli  hold  good 
in  all  gynecologic  vork.  Most  important  of  these  are  the  lim- 
itations natural  to  the  parts.  Unforeseen  accidents  and  com- 
plications occurring  in  the  course  of  the  operation  are  made  more 
difficult,  and  success  materially  interfered  with,  vhen  working 
under  such  disadvantages.  The  only  reason  why  vaginal  sec- 
tion is  considered  less  formidable  than  the  abdominal  is,  that 
the  uterus  is  opened  extraperitoneally.  Of  the  two  operations, 
the  former  is  the  more  difficult  to  do;  and  as  a  surgical  proce- 
dure it  demands  the  same  exactness  in  asepsis,  hand-cleansing, 
preparation  of  instruments,  and  sterilization  of  dressings. 

278 


VAGINAL  CESAREAN  SECTION  279 

Ample  Pelvic  Diameters. — One  sliould  not  attempt  to  deliver 
by  the  vaginal  route  in  the  presence  of  an  absolute  indication 
for  abdominal  section,  given  by  the  pelvic  diameter. 

Mobility  of  the  Uterus. — The  soft  parts  must  admit  of  the 
necessary  technic.  Only  when  the  uterus  is  freely  movable  and 
the  cervix  can  be  drawn  down  to  the  introitus  is  the  operation 
easily  performed.  If  the  tissues  are  much  swollen,  or  if  there  is 
abnormal  resistance  of  the  parametrium  or  of  the  fundus  vaginse, 
vaginal  hysterotomy  becomes  very  difficult. 

Asepsis  of  the  Birth  Canal. — While  an  aseptic  tract  guaran- 
tees a  reactionless  recovery,  a  slight  rise  of  temperature  does 
not  constitute  an  absolute  contraindication.  If  sepsis  is  mani- 
fest, however,  the  undertaking  becomes  extremely  risky,  since 
not  only  the  wound  itself  becomes  purulent,  but  the  process  may 
go  on  to  a  general  infection. 

PREPARATIONS 

The  patient  is  placed  in  the  lithotomy  position  on  the  operat- 
ing table,  the  thighs  everted  and  the  knees  supported.  The 
pubes  should  be  shaved,  and  the  vulva  and  vagina  thoroughly 
cleansed  and  disinfected.  Catheterization  of  the  bladder  must 
not  be  overlooked.  Simple  loose  draping  of  the  lower  body  is 
never  satisfactory,,  for  it  is  continuously  becoming  disarranged. 
Sterile  leggings  that  extend  to  the  groin  and  fasten  about  the 
waist  are  easily  put  on  and  will  not  come  off.  Two  assistants, 
one  on  either  side,  an  anesthetist,  and  a  nurse  are  needed. 

The  following  instruments  should  be  sterilized:  scalpels,  a 
number  of  artery  forceps,  two  toothed  forceps,  for  grasping  the 
portio  vaginalis,  tissue  forceps,  scissors  (both  straight  and 
curved),  needle-holder,  needles,  a  weighted  speculum,  retractors, 
sponge  probangs. 

For  suture  material,  twenty-day  catgut  in  the  smaller  sizes 
generally  is  used,  though  silk  or  linen  is  preferred  by  some  sur- 
geons. In  other  respects  the  preparations  are  the  same  as  for 
abdominal  section. 


280 


THE    SURGICAL   PROCEDURES 


TECHNIC 

Very  frequently,  and  especially  in  the  primii3ara,  it  is  desira- 
ble to  enlarge  the  introital  opening  by  incising  the  vulvovaginal 


Fig.    158. — N'aginal   cesarean    section.      Severing   the   portio   vaginalis. 


tissue  at  one  side  of  the  perineum.     To  do  this  an  assistant  in- 
troduces his  index  finger  into  the  vagina  on  the  left  side,  the  opera- 


VAGINAL  CESAREAN  SECTION 


281 


tor  the  index  finger  on  the  right  side.  Putting  the  posterior 
commissure  on  stretch,  an  incision  is  made  midway  between  the 
anus  and  the  ischial  tuberosity,   going  deep  enough  to  include 


Fig.    159. — Separating  and   pushing  back  the   bladder  from  the   cervix. 


the  musculature  of  the  pelvic  floor.     The  section  may  sometimes 
have  to  be  carried  as  high  as  the  vault  of  the  vagina.    Numerous 


282  THE    SURGICAL   PROCEDURES 

severed  vessels  will  need  to  be  ligated.  The  gaping  wound  is 
loosely  packed  with  gauze,  and  the  vagina  widely  retracted. 
The  anterior  lip  of  the  portio  vaginalis  is  grasped  on  both  sides 
of  the  middle  line  with  vulsella,  and  drawn  down  as  far  as  pos- 
sible. 

Beginning  at  a  point  at  about  2  cm.  below  the  urethral  open- 
ing, the  everted  and  stretched  vaginal  wall  is  incised  longitudi- 
nally as  far  as  the  cervicovaginal  junction,  care  being  taken  to 
cut  through  only  the  mucous  membrane  (Fig.  158).  In  the  lower 
third  of  this  section  will  be  seen  the  slightly  bulging  border  of 
the  bladder,  which  comes  more  clearly  into  view  as  the  vagina 
on  both  sides  is  freed  from  the  cervix  (Fig.  159).  The  space 
beneath  is  now  penetrated  with  the  upper  point  of  the  scissors,  and 
further  separation  made  between  the  bladder  and  the  uterus. 
This  is  best  clone  with  the  gauze  sponge  held  between  the  thumb 
and  finger,  or  by  gauze  worn  as  a  cot  over  the  finger.  A  narrow 
speculum  at  first,  a  wider  one  later,  introduced  into  the  vesico- 
uterine space,  serves  to  keep  the  bladder  up  out  of  the  way, 
and  expose  the  denuded  isthmus  of  the  cervix.  Thus  freed,  the 
organ  is  opened  with  straight  scissors,  the  section  beginning 
at  the  portio  vaginalis  and  extending  up  to  the  peritoneal  boun- 
dary. As  the  operator  cuts,  his  assistants,  who  maintain  a  firm 
hold  on  the  portio  with  vulsella,  separate  the  incised  wall  and 
make  downward  traction  at  the  same  time.  Performed  in  this 
way,  there  is  little  danger  of  wounding  the  bladder.  The  am- 
niotic sac  is  likely  to  be  opened,  so  that  the  fluid  escapes,  but 
no  harm  is  done  thereby. 

If  the  fetus  is  small,  the  anterior  section  will  give  sufficient 
opening  for  its  passage;  but  in  large  babies  it  often  becomes 
necessary  to  enlarge  the  aperture  by  extending  the  incision 
posteriorly.  The  hand  passed  into  the  uterus  and  withdrawn  closed 
gives  a  fairly  satisfactory  estimate  of  proportions,  but  a  more  sat- 
isfactory way  is  to  introduce  a  collapsed  hydrostatic  bag,  distend 
it,  and  continue  the  section  until  the  opening  is  large  enough  to 
permit  its  delivery.  It  is  better  to  make  the  wound  a  little  too 
large  than  a  little  too  small,  for  the  reason  that  if  it  is  too  small 
and  the  child  is  extracted  at  the  expense  of  the  tissues,  the  resulting 
laceration  becomes  more  of  a  problem  than  a  clean-cut  wound. 


VAGINAL    CESAREAN    SECTION 


283 


To  open  the  cervix  posteriorly  the  vagina  is  first  separated  trans- 
versely at  its  cervical  junction,  and  the  pouch  of  Douglas  is 
pushed  out  of  the  way  with  a  probang. 

All  instruments  are  now  removed,  and  the  delivery  of  the  child 
proceeded  with.    If  the  head  lies  deep  in  the  pelvis,  the  forceps 


>;-     - 

1                         -S^*- 

,'/ 

1  ^ 

\ 
\ 

\ 

\ 

/  •'  i 

1 

Fig.    160. — Closing  the   vaginal   mucous   membrane. 


is  applied;  if  high,  version  and  extraction  are  done.  If  the  child 
is  dead  or  nonviable,  craniotomy  is  indicated.  There  is  always 
danger  of  lacerating  the  uterus  if  one  proceeds  too  vigorously; 
the   operator,   therefore,   should  be   prudent   in   the   use   of  his 


284 


THE    SURGICAL   PROCEDURES 


strength.  The  placenta  should  be  expressed  at  once.  If  this 
is  not  easy  of  accomplishment,  it  should  be  removed  manually. 
To  delay  its  delivery  is  not  desirable,  because  with  the  loss  of 
time  there  is  a  needless  loss  of  blood,  which  should  be  kept  as 
near  the  minimum  as  possible. 


Fig.    161. — Closing    the   incision    in    the    cervix. 

As  a  rule  the  uterus  contracts  well,  especially  when  pituitary 
extract  or  ergot  has  been  given  preliminary  to  making  the  sec- 
tion. In  atonic  bleeding,  hot  irrigations  are  of  value ;  and,  in 
ease  of  necessity,  the  cavity  of  the  uterus  may  temporarily  be 


VAGtmAL    CESAREAN    SECTION  285 

packed  with  iodoform  gauze.     Diihrssen,  Doderlein,  and  others 
make  it  a  iDractice  to  do  this  in  every  case. 

The  retractor  is  now  reintroduced  and  the  separated  edges  of 
the  cut  uterus  brought  in  apposition  with  forceps,  not  depending 
on  a  single  vulsellum  on  each  side,  but  making  use  of  several  if 
considerable  traction  must  be  made  on  the  tissues  in  order  to 
bring  the  upper  end  of  the  incision  into  view.  Beginning  at  this 
point,  the  wall  of  the  uterus  down  to  the  external  os  is  united 
with  interrupted  twenty-day  catgut;  this  completed,  the  sutur- 
ing of  the  anterior  vaginal  wall  follows  (Fig.  160).  If  the  cervix 
has  been  opened  behind,  as  well  as  in  front,  the  posterior  incision 
should  be  repaired  first,  all  suture  knots  being  tied  within  the 
canal  (Fig.  161).  The  episiotomy  wound  made  at  the  beginning 
of  the  operation  may  require  both  buried  and  superficial  sutur- 
ing.    (See  Episiotomy,  page  336.) 

PROGNOSIS 

For  the  mother,  the  prognosis  is  favorable;  her  life  is  not 
greatly  endangered  by  it,  and  the  gynecologic  sequela3  are  no 
more  serious  than  those  following  a  difficult  instrumental  de- 
livery. But  for  the  child,  the  outlook  is  not  so  good,  the  baby 
often  succumbing  to  the  violence  of  delivery.  Of  the  viable  chil- 
dren, about  33  per  cent  are  lost.  In  the  presence  of  edema,  j)elvic 
contraction,  and  in  large  children,  the  fetal  mortality  runs  very 
high  and  the  maternal  mortality  reaches  about  14  per  cent. 
This  does  not  mean  that  the  operation  itself  is  very  serious,  for 
only  about  2  per  cent  of  the  mothers  die  from  this  cause  alone ; 
but  that  the  complication  making  the  operation  necessary  is  se- 
rious. 

For  the  following  excellent  reports,  I  am  indebted  to  Profes- 
sor Hammersehlag. 

Case  1. — Eclampsia  with  six  seizures;  death  following  vaginal  section. 
Aged  16;  primipara.  Startlingly  anemic;  pupils  wide;  pulse  small  and  fre- 
quent; introitus  and  vagina  contracted;  portio  vaginalis  preserved;  os  uteri 
dimpled. 

Operation  :  Large  paravaginal  section ;  hemorrhage  controlled.  The  portio 
was  found  edematous-  and  easily  torn ;  in  attempting  to  bring  it  down,  the 
whole  posterior  lip  tore  away.  With  great  difficulty  the  vaginal  wall  was 
separated,  and  the  bladder  pushed  out  of  the  way.     Not  being  able  to  expose 


286  TPIE    SURGICAL   PROCEDURES 

the  anterior  cervical  wall  with  a  speculum,  the  uterine  section  was  made  mainly 
by  sense  of  touch.  The  child  was  turned  and  extracted,  but  only  after  great 
exertion.  The  placenta  was  expressed.  The  walls  of  the  uterus  were  sutured 
together  as  far  up  as  possible,  and  the  cavity  tamponaded.  Seven  hours  later, 
the  patient  died. 

Autopsy:  The  peritoneum  was  intact.  The  parametrium,  especially  on  the 
left  side,  was  greatly  distended  with  coagulated  blood,  the  hematoma  extending 
retroperitoneally  nearly  to  the  kidney.  The  vagina  and  uterus,  with  the  excep- 
tion of  a  rent  in  the  upper  angle  of  the  section,  were  found  well  sutured. 
Through  this  tear,  which  was  about  an  inch  long,  had  occurred  the  fatal 
li  emorrhage. 

Case  II. — Eclampsia  with  ten  seizures,  accompanied  by  severe  coma.  Aged 
27;  primipara.  Vaginal  cesarean  section.  Portio  shortened,  and  os  merely 
dimpled.  Vaginoperineal  incision.  Could  not  draw  the  cervix  down;  marked 
friability  of  the  tissues.  Anterior  vaginal  wall  and  cervix  separated  and  re- 
tracted; bladder  shoved  out  of  the  way.  The  uterine  incision  was  carried 
high.  Child  delivered  with  forceps.  The  bladder  was  torn  for  an  inch  in  a 
cross  direction.  Immediate  repair  of  the  organ  failed  to  close  the  opening; 
a  fistula  developed,  which  later  was  cured  by  operation  after  two  attempts. 

Case  III.^Eclampsia.  Patient  Avas  brought  to  the  hospital  after  four  seiz- 
ures; delivered  by  vaginal  section;  continued  to  have  convulsions.  Aged  21; 
primipara.  Comatose  condition.  Temperature  normal ;  pulse  152.  Urine  nearly 
solid  with  albumin.     Prognosis  serious. 

Examination :  About  term.  Vertex  position ;  cervix  undilated  ;  vagina  con- 
tracted. 

Section  and  delivery.  Portio  and  vagina  separated  crosswise  in  anterior 
vault.  Bladder  pushed  out  of  the  way.  Cervix  opened  between  vulsella  up  to 
the  peritoneal  origin,  the  amnion  rupturing.  Forceps  applied  in  transverse 
diameter ;  head  delivered  slowly ;  wound  margin  very  taut.  Rupture,  extending 
up  the  right  side  for  nearly  an  inch  and  a  half  beyond  the  angle  of  incision. 
Placenta  expressed.  The  incision  and  tear  were  united  by  interrupted  catgut 
sutures.  Uterus  tamponed  with  iodoform  gauze,  serving  to  keep  the  cervix 
open  and  allow  the  lochia  free  drainage.  The  loss  of  blood  amounted  to 
500  c.c.    The  child  lived  and  was  of  average  size. 

Immediately  following  the  operation,  the  patient  had  the  eighth  convulsion. 
She  was  given  subcutaneously  500  c.c.  of  saline  infusion.  There  was  a  pause 
then  of  six  hours,  after  which  the  attacks  began  again,  continuing  to'  recur 
at  intervals  of  from  five  minutes  to  an  hour  and  a  half.  Altogether  there  were 
twenty  convulsions.  There  was  tracheal  rattling;  the  temperature  rose  to  105 
degrees;  the  pulse  reached  132;  and  there  was  continued  coma.  After  the 
tenth  attack,  2  gm.  of  chloral  hydrate  were  given  by  enema.  After  the  fif- 
teenth seizure,  a  hypodermic  of  morphine  was  injected.  Camphorated  oil  and 
saline  infusion  were  made  use  of.  It  Avas  thought  possible  that  the  iodoform 
gauze  in  the  uterus  might  be  the  exciting  cause  of  the  convulsions,  and  it  was 
removed.  There  were  no  more  spasms,  the  temperature  came  down  rapidly  to 
normal,  and  the  pulse  to  96.  Recovery  continued  undisturbed.  The  mother 
and  baby  Avere  discharged  well. 


PART   II 

MANAGEMENT  OF  THE   SERIOUS  COMPLICA- 
TIONS 


CHAPTER  XIV 

THE  THIRD  STAGE  OF  LABOR 

The  Physiology  of  Cleavage  and  Expulsion. — It  is  an  observa- 
tion easily  made  that  the  uterus,  as  soon  as  the  child  leaves  it, 
becomes  smaller,  the  fundus  sinking  to  about  the  level  of  the 
'umbilicus.  Coincident  with  this  reduction  in  size  is  a  readjust- 
ment of  structure,  which  causes  the  placenta  to  be  cleft  from 
its  attachment,  a  process  that  takes  on  the  average,  somewhat 
less  than  a  half  hour  to  complete.  In  this  process  of  cleavage, 
three  acts,  or,  more  correctly  speaking,  three  phases  of  a  single 
act,  take  place,  relaxation,  hemorrhage  and  contraction.  The 
placental  site  expands,  the  intervillous  spaces  and  maternal  ves- 
sels fill  with  blood,  and,  finally,  the  cycle  ends  in  a  contraction. 
This  is  repeated  several  times  before  the  placenta  becomes  fully 
separated  from  its  decidual  base.  As  the  placenta  loosens,  the 
layer  of  muscle  contracts  with  each  gain  until  the  wall  of  the 
uterus  at  this  point  becomes  as  compact  as  in  other  portions  of  the 
organ.  Failure  to  contract  accounts  for  most  of  the  troublesome 
hemorrhage  that  occurs  during  the  placental  stage  and  the  period 
immediately  following  it. 

Many  agree  with  Schultze  that  separation  starts  near  the  cen- 
ter of  the  placenta  (Fig.  162)  ;  others  just  as  ardently  contend 
with  Duncan  that  it  begins  at  the  margin  (Fig.  130).  If  the 
cleavage  begins  in  the  center,  there  is  little  escape  of  blood  until 
after  the  placenta  is  delivered,  when  one  may  find  extravasated 
blood  adhering  to  its  uterine  surface  (retroplacental  hematoma) ; 

287 


ZbS  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

if  separation  begins  at  the  edge  of  the  placenta,  the  l^loocl  readily 
escapes,  and  no  such  clot  forms. 

After  a  few  contractions,  generally  not  more  than  eight  or 
ten,  detachment  becomes  complete,  and  the  placenta  moves  into 
the  lower  confines  of  the  nterns.  As  cleavage  and  extrusion  go 
on,  the  after-birth  becomes  inverted,  taking  with  it  the  amnion, 
which  also  turns  inside  out  as  it  comes  away.  This  is  particularly 
true  if  separation  is  of  the  Schultze  type. 

The  placenta,  which  now  comes  to  lie  in  the  lower  segment  of 
the  uterus,  or,  perhaps,  in  the  vault  of  the  vagina,  can  not  be 


Fig.    162. — Placental   separation   and    expulsion   as   described   by    Schultze. 


expelled  by  the  uterus  alone  and  another  force,  that  of  intra- 
abdominal pressure,  is  necessary  to  complete  the  process.  The 
mere  presence  of  the  bulky  after-birth  in  the  genital  tract  may 
excite  sufficient  activity  to  cause  its  passive  expulsion,  but  in 
nearly  every  instance  the  patient  is  obliged  to  make  some  volun- 
tary effort.  Upon  its  complete  evacuation,  the  uterus  subsides 
into  a  state  of  tonic  contraction,  which  continues  throughout  the 
puerperium. 

Managfement. — Two  very  important  practices  should  govern  the 
obstetrician  in  the  management  of  the  third  stage  of  labor:  first, 
never  to  disturb  its  normal  course,  and,  second,  immediately  to 


THE    THIRD    STAGE    OF    LABOR 


289 


correct  any  deviations  from  the  normal.  Let  ns  consider  for  a 
moment  the  normal  course. 

As  soon  as  the  child  is  born  the  delivered  woman  is  straight- 
ened out  in  bed  on  her  back,  a  fresh  sterile  dressing  is  applied  to 
the  vulva,  and  she  is  allowed  to  rest.  If  the  bladder  has  become 
overdistended  with  urine  during  the  labor,  it  should  be  emptied ; 
otherwise  the  process  of  placental  detachment  and  expulsion 
should  not  be  interfered  with. 

For  the  first  few  minutes  the  physician  is  concerned  in  the 
amount  of  blood  that  is  lost,  and  the  height,  position,  and  hard- 
ness of  the  uterus.  If  the  fundus  remains  near  the  level  of  the 
umbilicus,  and  is  hard,  the  cavity  of  the  uterus  contains  no  great 


Fig.    163. — Placental    separation   and   expulsion   as    described   by    Duncan. 


amount  of  blood;  if  the  organ  is  large  and  soft,  there  may  be 
considerable. 

Unless  there  is  some  special  indication  for  manipulation,  the 
uterus  should  be  left  entirely  alone.  If  a  severe  hemorrhage  de- 
mands attention,  as  may  be  the  case  in  a  flaccid  atonic  uterus, 
its  contraction  may  then  be  encouraged  by  gentle  massage, 
made  with  the  tips  of  the  fingers. 

When  completely  detached,  the  placenta  should  be  expelled  by 
abdominal  pressure.  After  half  an  hour  it  may  be  considered 
that  separation  has  taken  place,  since  in  the  majority  of  cases 
it  is  effected  in  a  much  shorter  time.     Separation  being  estab- 


290  MANAGEMENT    OF    THE    SERIOUS    COMPIJCATIONS 

lished,  it  is  suggested  to  the  patient  that  she  ''bear  down;" 
and  at  the  same  time  the  physician  makes  firm  pressure  on  the 
fundus  with  his  hand.  No  other  manipulations  are  necessary  in 
an  absolutely  normal  delivery  of  the  placenta. 

If,  after  half  an  hour,  the  placenta  has  not  become  detachedj 


Fig.    164. — Expressing  the  placenta. 


the  first  thing  to  try  is  that  of  expression.  The  uterus  is  brought 
to  the  middle  line  and  massaged  until  it  becomes  well  contracted. 
It  is  then  grasped  with  the  hand,  the  fingers  lying  behind  and 
the  thumb  in  front  of  the  fundus,  and  pressure  made  in  a  down- 


THE    THIRD    STAGE    OF    LABOR 


291 


ward  direction.  Delivery  is  generally  successful  the  first  time 
it  is  attempted;  but,  in  case  it  is  not,  other  trials  may  be  made 
(Fig.  164). 

The  placenta  should  be  inspected  as  soon  as  it  is  delivered. 
Spread  out  on  the  palm  of  the  hand,  its  maternal  surface  is  ex- 


Fig.   16S. — Placenta  with  three  secondary  portions.      (Bumm.) 

amined  for  defects  and  irregularities.  Normally  it  is  covered 
with  a  gray  coating  of  decidua,  the  margins  blending  smoothly 
into  the  amnion.  Torn  vessels  found  running  into  the  amnion 
indicate  that  an  accessory  part  of  the  placenta  has  been  left  be- 
hind, and  show  its  connection  with  the  larger  structure.  (Fig. 
165.) 


292  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

Disturbances. — The  disturbances  tliat  occur  in  the  third  stage 
of  labor  are  mostly  the  result  of  imperfect  cleavage  or  the  failure 
to  expel  the  placenta  after  it  becomes  cleft.  The  first  of  these 
may  be  due  to  various  causes,  such  as  inertia  of  the  uterus,  ab- 
normally close  attachment  of  the  placenta,  its  unusual  size  and 
irregular  form,  interstitial  tumors,  etc.  The  inertia  may  accom- 
pany a  very  rapid  emptying  of  the  uterus,  as  by  operation ; 
it  may  succeed  upon  a  long  and  exhausting  labor;  it  may  result 
from  overdistention  of  the  uterus,  as  in  hydramnion,  and  twins ; 
or  it  may  be  of  infectious  origin.  The  intimate  attachment  of 
the  placenta  comes  from  endometrial  processes,  the  decidua  un- 
dergoing pathologic  thickening ;  or,  as  may  occur  in  atrophic  de- 
velopment of  the  decidua,  the  chorionic  villi  may  penetrate  the 
underlying  muscle.  Abnormally  firm  union  between  the  pla- 
centa and  uterus  may  also  accomjDany  a  low  attachment  of  the 
embryo,  as  in  placenta  previa.  Infectious  diseases  and  nephritis, 
too,  are  said  to  favor  it.  It  is  to  be  observed  in  this  connection 
that  having  once  occurred,  a  disturbance  in  separation  is  quite 
likely  to  occur  again  should  pregnancy  be  repeated. 

Disturbances  of  expulsion  are  due  mainly  to  insufficient  ab- 
dominal pressure;  but  there  ioQ.a.j  be  other  causes.  A  not  unusual 
one  arises  in  the  uterus  itself.  A  contraction  of  the  internal 
OS  or  of  the  ring  of  Bandl  above  it,  may  be  so  marked  as  to  effectu- 
ally imprison  the  placenta.  Such  a  condition  is  most  likely  to 
follow  an  operative  delivery  in  the  first  stage  of  labor,  performed 
before  the  lower  segment  has  become  thinned  out  and  the  inner 
OS  fully  effaced.  Faulty  management  and  improper  manipula- 
tions are  also  responsible  at  times  for  such  action  of  the  uterus. 
I  nearly  lost  a  patient  by  trying  to  express  the  placenta  when, 
after  a  reasonable  effort  without  success,  my  continued  manipu- 
lations served  only  to  drive  the  uterus  to  greater  resistance. 

The  amount  of  disturbance  to  accompany  the  third  stage  of 
labor  depends  largely  on  the  completeness  or  incompleteness  of 
placental  detachment.  If  no  separation  at  all  takes  place,  noth- 
ing particular  is  noticeable  until  decomposition  sets  in.  AYhen 
partial  separation  takes  place,  the  symptom-complex  will  depend 
on  the  amount  of  bleeding  that  follows.  With  the  outlet  un- 
obstructed, the  blood,  which  is  of  a  dark  venous  color,  flows  in 


THE    THIRD    STAGE    OP    LABOR  293 

a  continuous  stream  from  the  introitus;  but  when  the  outlet  is 
occluded,  as  it  may  be  with  membranes  or  with  a  part  of  the 
placenta  itself,  the  blood  accumulates  above  the  obstruction. 
The  signs  of  anemia,  hoAvever,  are  the  same,  whether  the  blood  is 
discharged  or  retained.  In  either  case  the  symptoms  become 
noticeable  as  soon  as  the  loss  goes  beyond  a  certain  amount,  a 
liter  being  quite  sufficient  to  cause  pallor.  The  pulse,  too,  be- 
comes small  and  frequent,  and  the  patient  complains  of  being 
cold,  and  is  drowsy  and  apathetic.  If  the  hemorrhage  continues 
unchecked,  it  is  followed  by  swooning,  vomiting,  severe  dyspnea, 
profuse  sweating,  and,  eventually,  by  death.  The  normal  blood 
loss  is  between  300  and  500  c.c,  but  may  in  some  instances, 
amount  to  as  much  as  600  c.c.  without  going  beyond  the  bounds 
of  safety.  Much  depends,  of  course,  on  the  size  of  the  individual 
and  on  her  physical  health. 

If,  in  the  third  stage  of  labor,  hemorrhage  can  not  be  checked 
by  uterine  massage,  measures  must  be  undertaken  at  once  to 
empty  the  uterus  of  the  placenta,  since  only  after  it  is  out  of 
the  way  will  the  uterus  remain  contracted.  It  is  not  generally 
possible  to  express  the  placenta  before  it  is  wholly  loosened,  yet 
sometimes  it  will  come  away  with  one  or  mcire  cotyledons  missing, 
Even  after  the  placenta  is  detached,  its  expression  can  still  prove 
very  troublesome.  A  thick  abdomen,  for  example,  makes  it  ex- 
tremely difficult  to  span  the  uterus  effectively ;  and  oversensitive- 
ness,  extreme  anxiety,  and  fear  greatly  interfere  with  manipula- 
tion; and,  when  attempted,  it  only  serves  to  increase  the  rigidity. 
The  size  of  the  uterus,  too,  makes  considerable  difference.  If  it 
is  small,  as  in  premature  interruption  of  pregnancy,  very  little  can 
be  accomplished  by  pressure ;  if  it  is  very  large  and  wide,  as  in 
hydramnion,  it  is  hard  to  grasp.  All  such  hindrances  are  greatly 
lessened  by  narcosis. 

Contractions  of  the  internal  os  or  of  the  ring  of  Bandl  above 
can  so  effectually  lock  the  placenta  Avithin  the  uterus  as  to  make 
expression,  at  least  for  the  time  being,  impossible.  If  the  bleed- 
ing is  not  severe,  so  that  one  may  safely  defer  the  completion  of 
the  third  stage  for  a  time,  rest  should  be  enjoined  and  a  hypo- 
dermic of  morphine  and  ati'opine  allowed.  But  in  the  presence 
of  anemia  and  continued  hemorrhage,  the  immediate  removal  of 
the  placenta  is  necessary. 


294  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

MANUAL  DETACHMENT  OF  THE  PLACENTA 

Manual  detachment  of  the  placenta  should  be  undertaken  only 
when  other  measures  fail,  not  omitting  their  trial  under  narcosis. 

Indications 

The  Amount  of  Blood  Lost  Exceeding-  One  Liter. — Since  the 
bleeding  can  not  be  controlled  with  the  placenta  still  undelivered, 
its  removal  becomes  necessary- 
Retention  of  the  Placenta  Without  Bleeding. — So  long  as  the 
placenta  remains  adherent,  there  can  be  no  hemorrhage  ;  and  were 
it  not  for  the  decomposition  that  follows,  it  might  be  left  in- 
definitely. Its  presence,  however,  opens  a  field  of  sapremic  ac- 
tivity, not  to  mention  the  more  virulent  forms  of  infection.  Be- 
sides, there  is  always  the  possibility  of  the  placenta  becoming  de- 
tached, partially,  if  iiot  completely,  and  serious  hemorrhage  tak- 
ing i3lace ;  therefore,  its  retention  is  a  constant  menace  that 
should  not  be  suffered  to  continue  for  many  hours,  even  if  the  loss 
of  blood  be  negligible. 

Escape  of  the  Placenta  Through  a  Rupture  in  the  Uterus. — ■ 
Should  the  detached  placenta  find  its  way  through  a  rent  in  the 
uterus,  the  hand  must  seek  it.  AVhether  by  way  of  the  vagina  or 
abdomen  will  be  discussed  later.  (See  Rupture  of  the  Uterus, 
page  308.) 

Positive  Proof  That  a  Portion  of  the  Placenta  Has  Been  Left. — 
If,  after  very  painstaking  inspection,  one  is  in  doubt  as  to 
whether  or  not  a  part  of  the  placenta  has  been  retained,  he  may 
await  the  development  of  symptoms  before  introducing  the  hand; 
but  if  he  is  positive  that  a  piece  of  considerable  size  has  been  left, 
he  should  remove  it.  Retained  pieces  of  membrane  do  not  cause 
hemorrhage,  and  are  not  responsible  for  puerperal  morbidity  to 
any  great  degree. 

Constriction  of  the  Internal  Os  or  of  the  Contraction  Ring. — 
The  presence  of  such  a  constriction  can  make  delivery  of  the 
placenta  impossible,  except  by  instrumental  or  manual  means; 
and  then,  if  the  contraction  is  marked,  its  preliminary  dilatation 
may  be  required  before  the  hand  can  be  passed. 


THE    THIRD    STAGE    OF    LABOR  295 

Technic 

The  patient  is  placed  crosswise  on  the  hed  in  the  usual  position 
for  operation,  and  an  exceptionally  careful  disinfection  is  made 
of  the  vagina  and  external  parts.  As  always  before  operating,  the 
bladder  should  be  emptied  by  catheter.  In  desperate  conditions 
one  may  proceed  without  anesthesia,  but  usually  there  is  no  great 
risk  in  narcosis  if  given  cautiously.  Very  little  of  the  agent  is 
needed  because  of  the  lowered  sensation  due  to  anemia.  If  one 
"has  to  deal  with  a  cavity  no  longer  aseptic,  it  should  be  thoroughly 
irrigated  with  a  mild  antiseptic  before  beginning  the  operation. 
For  this  purpose  a  solution  of  iodine  (2  c.c.  of  the  tincture  to  2 
liters  of  water)  serves  the  purpose  well.  The  bulk  of  the  germs 
are  either  washed  away  or  destroyed  by  it.  The  hands  and  arms 
of  the  surgeon  are  thoroughly  disinfected ;  and  it  is  particularly 
important  that  a  glove  be  worn. 

Kneeling  before  the  patient,  the  operator  takes  hold  of  the 
protruding  cord  with  one  hand,  making  gentle  traction  upon  it, 
while  with  the  other  he  follows  along  its  course  through  the  vagina 
into  the  uterus  and  on  to  the  placenta.  When  this  area  is  reached, 
his  hold  on  the  cord  is  released,  and  the  opened  hand  is  applied 
externally  to  the  fundus,  which  is  held  firmly  against  the  internal 
hand.  With  the  ulnar  side  of  the  hand  pressing  against  the  utero- 
placental border,  the  palm  turned  toward  the  placenta,  separation 
is  begun  by  a  back  and  forth  movement,  beginning  at  the  most 
distant  point  of  attachment  and  continued  toward  the  operator 
(Fig.  166).  Very  often  a  partial  loosening  has  already  taken 
place,  which  is  an  aid  in  determining  the  proper  layer;  but  one 
will  occasionally  meet  with  so  much  resistance  that  he  will  be  in 
doubt,  and  may  find  that  he  is  working  in  the  substance  of  the 
placenta  itself  or  in  the  deeper  strata  of  the  uterine  wall.  Rarely, 
though,  is  the  connection  between  them  so  intimate  as  to  be  mis- 
leading.    Generally,  separation  is  easily  accomplished. 

The  operation  is  accompanied  by  a  marked  hemorrhage,  which 
stops,  however,  as  soon  as  detachment  is  complete.  The  placenta  is 
grasped  in  the  hand,  and  brought  out  of  the  uterus  in  as  compact  a 
state  as  possible.  Along  with  it  follows  the  amniotic  membrane, 
which  peels  readily  from  the  decidua.  To  make  sure  no  part  of  the 
after-birth  still  remains,  it  is  advised  that  the  hand^  after  further 


296 


MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 


disinfection,  be  reintroduced  and  tlie  cavity  carefully  explored. 
With,  the  exception  of  the  placental  site,  which  normally  is  rough 
and  uneven,  the  entire  intrauterine  surface  feels  smooth.  The 
operation  is  concluded  with  a  hot  saline  intrauterine  douche,  the 


Fig.   166. — Manual  separation  and  removal  of  the  placenta.      (After  Bumm.) 


purpose  of  which  is  quite  as  much  to  stimulate  contraction  as  to 
wash  away  loose  particles  of  tissue,  clots,  and  germs. 

Undertaken  with  the  patient  in  the  dorsal  position,  manual  de- 
tachment of  the  placenta  is  more  difficult  than  the  foregoing  would 
make  it  appear,  if  the  attachment  is  ^o  the  anterior  instead  of  the 


THE    THIRD    STAGE    OF    LABOR  297 

posterior  wall  of  the  uterus.  In  this  position  the  placenta  is  hard 
to  reach.  One  can  curve  the  arm  forward  and  separate  it  from 
the  uterus  with  the  ends  of  the  fingers,  as  shown  in  Fig.  166 ;  but 
it  will  be  more  uniform  with  the  technic  described  if  the  patient 
be  turned  on  the  side.  This  need  not  disturb  the  operator,  nor  com- 
plicate the  situation.  With  the  hand  still  in  the  uterus,  the 
patient's  leg  is  carried  over  the  physician's  head  as  the  change  from 
a  dorsal  to  a  lateral  position  is  made.  One  is  cautioned,  however, 
not  to  withdraw  the  placenta  with  the  woman  in  this  posture  as 
it  increases  the  danger  of  air  embolism. 

A  not  infrequent  complication,  one  that  materially  interferes 
Avith  the  removal  of  the  placenta,  is  the  contraction  of  the  cervix, 
and  this  must  be  overcome  before  the  hand  can  be  passed  into  the 
cavity  of  the  uterus.  Beginning  with  one  or  two  fingers,  others  are 
introduced  in  succession  until  the  canal  once  more  becomes  dilated. 
If  it  is  only  a  portion  of  the  placenta  which  remains,  it  may  be  pos- 
sible to  remove  it  through  a  cervix  only  partially  dilated.  If  one  or 
two  fingers  can  be  passed  through  the  canal,  such  pieces  may  be  dis- 
lodged ;  and  with  the  other  hand  applied  over  the  fundus,  they  may 
be  expressed. 

If  the  loss  of  blood  is  severe,  not  only  must  the  immediate 
hemorrhage  be  controlled,  but  the  anemia,  as  well,  relieved.  It  may 
be  necessary  in  some  instances  to  deal  with  the  anemia  before  re- 
moving the  placenta,  particularly  if  the  hemorrhage  has  abated 
somewhat.  And,  again,  both  anemia  and  hemorrhage  may  be 
dealt  with  at  the  same  time,  an  assistant  infusing  the  patient,  the 
surgeon  seeking  to  check  the  bleeding. 

PROGNOSIS 

The  prognosis  is  influenced  by  two  things,  sepsis  and  trau- 
ma. If  external  manipulations  alone  are  made,  infection  is  not 
possible.  As  for  the  injuries,  most  of  them  are  in  the  nature  of 
bruises  that  jjass  away  unnoticed.  Sometimes,  however,  a  more 
serious  injury  than  mere  contusion  may  result  from  pressure, 
such  as  inversion  of  the  uterus.  The  dictum  of  Crede,  ''never  to 
attempt  expression  when  the  uterus  is  flaccid,"  should  not  be  for- 
gotten ;  and  a  dimpling  of  that  organ,  which  is  sometimes  to  be 
made  out  if  the  abdominal  wall  is  thin,  should  warn  one  against 
further  pi'essure. 


298 


MAXAGEMEXT    OF    THE    SERIOUS    COMPLICATIOXS 


TREATMENT  OF  INVERSION 

Because  of  its  close  comicetion  with  the  delivery  of  the  placenta. 
a  few  words  about  the  treatment  of  inversion  will  not  be  out  of 
place  here.     (Fig.  167.) 

The  fundus  is  grasped  at  its  most  dependent  part,  and,  together 
with  the  attached  placenta,  pushed  back  into  the  pelvis.    Not  suc- 


167. — Complete    inversion    of    the    puerperal    uterus,    with    the   placenta    still    attached. 

(Bumm.) 


ceeding  thus  easily  in  restoring  it  to  its  normal  relations,  one  may 
be  able  to  turn  it  back  if,  instead  of  applying  pressure  to  the  fun- 
dus, the  reduction  is  begun  at  the  cervix.  After  complete  restora- 
tion the  placenta  is  detached  manually,  and  the  cavity  packed  with 
gauze.  Only  when  the  placenta  has  become  partially  detached  does 
one  complete  its  separation  before  reducing  the  dislocation.     If 


THE    THIRD    STAGE    OF    LABOR  299 

neither  of  the  above  maneuvers  succeeds,  the  patient  should  be 
anesthetized  and  the  same  manipulations  repeated  under  narcosis. 
Unless  the  dislocation  can  be  corrected  very  shortly  after  it  occurs, 
and  rather  easily,  it  is  best  not  to  continue  the  manipulations  for 
more  than  a  few  minutes,  for  failure  only  causes  opposition  by  in- 
tensifying the  contractions.  The  next  thing  to  try  is  slow  re- 
duction by  means  of  gauze  packing  or  the  use  of  the  hydrostatic 
bag.  The  fundus  is  pushed  as  far  up  the  canal  with  the  hand  as  it 
will  go,  and  the  vagina  tamponed,  the  pressure  being  maintained 
by  a  firmly  applied  T-binder  or  with  the  hand.  The  bag  answers 
the  same  purpose,  but  it  is  rarely  available,  especially  in  general 
practice.  Reduction  by  it  is  accomplished  without  much  difficulty, 
except  when  the  inversion  is  of  long  standing.  It  then  becomes  a 
gynecologic  procedure. 

There  are  few  other  casualties  to  complicate  manual  detachment 
of  the  placenta.  Separation  at  some  point  other  than  through  the 
decidual  layer  may  occur  if  the  fingers  be  forced  into  structures 
having  fibrous  resistance.  An  injury  so  unwarranted  as  the 
penetration  of  the  vaginal  wall  with  the  hand,  is  not  unheard  of, 
though  this  could  hardly  happen  if  the  precaution  to  follow  up  the 
cord  to  its  insertion  is  taken. 

The  danger  most  to  be  fearcfl  in  manual  delivery,  is  that  of 
infection.  The  hand,  coming  as  it  does  in  contact  with  the  open 
lymph  and  blood  vessels,  inoculation  with  microorganisms  becomes 
extremely  easy.  Only  when  the  time  taken  to  secure  cleanliness 
may  cost  the  patient  her  life,  is  one  justified  in  omitting  any  part 
of  his  usual  precautions.  Rubber  gloves,  by  all  means,  should 
be  worn.  The  danger  of  course  is  increased  if  infection  already 
exists  in  any  part  of  the  birth  canal. 

Manual  delivery  of  the  placenta  would  seldom  be  necessary  if 
the  normal  third  stage  of  labor  were  more  carefully  conducted.  It 
should  never  be  undertaken  before  first  trying  other  and  safer 
methods,  not  forgetting  the  advantages  to  be  gained  by  narcosis. 
Untimely  manipulations,  massage,  and  premature  attempts  to  ex- 
press the  placenta  are  responsible  in  most  instances  for  the  con- 
ditions which  make  manual  interference  necessary. 


CHAPTER  XV 
POSTPAETUM  HEMORRHAGE 

Checking'  the  Hemorrhage. — In  the  way  of  hemostatic  drugs, 
ergot  and  pituitary  extract,  given  hypodermically  are  the  ones 
usually  administered.  In  anticipation  of  hemorrhage,  as  may  be 
the  case  in  twin  pregnancy  or  in  hydramnion,  it  is  well  to  give 
one  or  the  other  of  these  preparations  immec^iately  after  the 
delivery  of  the  placenta.  At  least  no  harm  is  likely  to  come  from 
their  use. 

If,  in  spite  ■  of  such  measures,  the  uterus  remains  in 
a  state  of  atony,  a  hot  antiseptic  douche  should  be  given,  partly 
in  the  uterus  and  partly  in  the  anterior  vault  of  the  vagina.  Mas- 
sage of  the  uterus  should  accompany  and  follow  the  irrigation. 
Should  the  hemorrhage  continue  unabated,  the  disinfected  gloved 
hand  may  be  passed  into  the  vagina,  and  the  uterus  anteflexed  and 
massaged  more  directly.  (Fig.  168.)  After  withdrawing  one 
hand,  the  other  should  still  press  the  uterus  against  the  symphysis 
until  all  danger  from  immediate  hemorrhage  is  past.  Sometimes, 
instead  of  merely  supporting  the  uterus,  the  hand  may  be  passed 
on  into  it  and  closed,  thus  making  counterpressure  even  more 
effective. 

The  hemorrhage  still  continuing,  constriction  of  the  body  after 
Momburg's  method  may  be  tried.  Rubber  tubing  (common  red 
rubber  gas  tubing),  a  couple  of  yards  in  length,  is  bound  about  the 
patient's  waist.  Once  around  is  not  enough;  it  should  go  around 
at  least  twice,  perhaps  three  times  (Fig.  169.)  Unless  the  con- 
striction is  powerful  enough  to  shut  off  the  arterial  circulation,  the 
lower  extremities  become  intensely  hyperemic  without  checking 
the  hemorrhage.  A  half -hour  is  as  long  as  the  tube  should  remain 
in  place.  Its  release  should  be  gradual,  else  the  greater  volume  of 
blood  thrown  suddenly  into  circulation  may  seriously  embarrass 
the  heart  action.  If  bleeding  starts  afresh  after  its  removal,  the 
tube  had  better  not  he  reapplied,  but  the  cavity  of  the  uterus 
tamponed  instead. 

300 


POSTPARTUM    HEMORRHAGE 


301 


To  simplify  the  procedure  of  packing  the  uterus,  the  cervix 
should  be  well  exposed  through  a  speculum,  and  drawn  down  to 
the  introitus.  The  gauze  pack  is  most  aseptically  applied  if  it  is 
introduced  directly  from  the  container  in  which  it  has  been  steri- 
lized. With  a  dressing  forceps,  it  is  carried  to  the  fundus  and  the 
Avhole  cavity  filled.  (Fig.  170.)  The  operator  can  better  .judge 
of  the  thoroughness  of  his  work  if  he  applies  one  hand  externally 


Fig.    168. — Bimanual  compression  of  the  uterus  in  postpartum  hemorrhage.     (After  Bumm.) 


to  the  fundus  Avhile  packing  with  the  other.  The  amount  of 
material  needed  will  vary  from  five  to  eight  yards  of  handbreadth 
iodized  gauze.  The  tampon  should  remain  undisturbed  for  twenty- 
four  hours,  and  then  be  cautiously  removed. 

After  hemorrhage  has  been  checked,  it  is  essential  that  the  uterus 
remain  contracted  for  at  least  two  hours.    Pressure  Avith  the  hand, 


302 


MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 


the  application  of  a  firm  Ijindcr,  or  the  overlaying  of  the  uterus 
with  a  bag  of  sand,  are  some  of  the  available  means  for  maintain- 
ing such  compression. 

Combating'  the  Anemia. — If  the  amount  of  blood  lost  has  been 
moderate,  it  requires  no  particular  consideration  other  than  the 
free  use  of  liquids,  such  as  coffee,  tea.  milk,  wine,  and  water  given 


Fig.    169. — Constriction    of   the  waist  with   the   Momburg   tube   to   control   hemorrhage. 


to  drink.  But  when  the  hemorrhage  has  been  great,  the  pulse 
small  and  rapid  (120)  or  lost  altogether;  when  the  patient  cries 
for  air,  complaining  that  the  room  is  close,  and  that  she  is 
nauseated  and  faint,  then  the  anemia  presents  serious  aspects,  and 
calls  for  more  active  treatment. 

First  of  all,  the  head  should  be  lowered,  the  pillow  taken  away, 


POSTPARTUM    HEMORRHAGE 


303 


and  the  foot  of  the  bed  elevated.  Bodily  heat  may  be  maintained 
by  means  of  hot  water  bottles  and  other  warm  objects  placed  about 
the  patient. 

Next  to  be  considered  is -the  blood  and  its  speedy  restoration. 


Fig.    170. — Packing  the   uterus   with   gauze. 

For  this  purpose  one  frequently  makes  use  of  saline  infusion,  intro- 
ducing the  solution  either  subcutaneously  or  per  rectum.  In 
the  hospital  the  necessary  apparatus  for  carrying  out  one  or  the 
other  of  these  procedures  is  at  hand,  and  little  time  need  be  lost; 
but  in  outside  practice  the  obstetrician  may  be  obliged  to  impro- 


304 


MANAGEMENT   OF    THE   SERIOUS    COMPLICATIONS 


vise  some  of  the  thing's  required.  He  should,  therefore,  always 
have  ready  in  his  satchel  an  infusion  cannula,  a  yard  or  more 
of  rubber  tubing,  a  metal  funnel,  and  several  six-gram  powders  of 
salt.  (One  such  powder  added  to  one  liter  of  water  makes  a 
solution  of  the  proper  strength.)  After  their  sterilization,  the  can- 
nula, tulnng,  and  funnel  are  connected,  and  the  solution  intro- 
duced by  gravitation  into  the  region  beneath  the  mammse.     Other 


Fig.    171. — Introducing   normal    salt   solution   into   the   basilic  vein   by    the   gravity   method. 

(Redrawn  from   JJdgar.) 

areas  than  this  are  sometimes  chosen,  but  they  are  less  comfortable 
when  injected  and  more  inaccessible  to  manipulation.  The  pro- 
cedure of  hj^podermoelysis  is  simple,  yet  one  seldom  sees  it  carried 
out  without  a  break  in  the  technic :  the  connections  come  apart,  the 
needle  becomes  plugged,  the  tubing  leaks,  or  the  solution  is  too  hot 
or  too  cold.     All  this  could  be  obviated  if  a  little  more  care  were 


POSTPARTUM    HEMORRHAGE 


305 


taken  to  see  that  everything  is  in  working  order  before  under- 
taking the  operation.  Hypodermoclysis  oliee  well  started  re- 
quires no  further  manipulation,  except,  perhaps  a  little  gentle 
massage  of  the  infiltrated  area  to  favor  absorption  and  to  relieve 
the  tumefaction  of  the  parts.  The  whole  process  should,  of  course, 
be  carried  out  as  aseptically  as  possible;  otherwise  it  may  be  fol- 
lowed by  the  development  of  a  phlegmon  at  the  site  of  injection,  or, 
perhaps,  may  end  in  a  general  infection.  It  is  also  important  that 
the  needle  be  made  to  enter  the  subcutaneous  tissue.     To  infiltrate 


-^ 


Fig.   172. — Basilic  vein   prepared   for  infusion,  and   the   cannula. 

the  skin  may  cause  its  necrosis.  When  properly  infused,  the  intro- 
duced fluid  is  quickly  absorbed.  A  similar  but  less  prompt  effect  is 
obtained  by  injecting  the  solution  into  the  rectum.  And,  in  suit- 
able cases,  infusion  of  normal  saline  into  a  vein  or  possibly,  the 
transfusion  of  blood  acts  even  better  than  either.  The  object 
of  all  such  therapy  is  to  tide  the  patient  over  the  crisis  of 
acute  anemia.  The  danger  past,  regeneration  of  the  blood  rapidly 
takes  place. 

An  altogether  different  method  of  temporarily  supporting  the 


]06 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


vital  centers  is  that  of  utilizinsj  the  blood  of  one  part  to  buoy  up 
another.  The  process  is  spoken  of  as  autotransfusion.  It  is  ac- 
complished by  comi)ression.  One  or  both  extremities  are  tightly 
Ijound  from  the  toes  to  the  g-roin  with  an  Esmarch  bandage, 
shutting  off  for  the  time  being  less  important  areas  in  order  that 
the  more  vital  centers  may  be  safeguarded.     The  procedure  is  ex- 


Fic 


-Introducing    normal    salt    solution    into    the    basilic    vein    by    the    air-ijressure 
method.      (Redrawn   from    Shears.) 


ceedingly  painful  and  should  not  be  continued  for  more  than  two 
hours.  If  maintained  for  a  longer  period,  the  constriction  may  re- 
sult in  serious  injury  to  the  soft  tissues,  especially  the  nerves.  And 
in  releasing  the  pressure  there  is  some  risk  of  producing  harmful 
hyperemia  in  the  extremity  with  collapse  of  the  patient  if  the 
volume  of  blood  in  the  isolated  area  is  restored  too  suddenly.     It 


POSTPARTUM    HEMORRHAGE  307 

sliould  be  rcesta1:)lished  slowly.  The  procedure  is  one  of  con- 
siderable ntility  and  easily  carried  out,  Ijut  it  is  not  altogether  free 
from  danger,  and  should  not  be  employed  except  in  an 
emergency. 

Atony  and  anemia  rarely  prove  fatal  in  childbirth,  if  the  de- 
livery, especially  of  the  placenta,  has  been  under  an  obstetrician  's 
personal  supervision.  But  unfortunately,  it  sometimes  happens 
that  one  sees  these  cases  for  the  first  time  after  severe  hemorrhage 
has  taken  place,  when  atony  and  anemia  have  become  too  profound 
to  respond  to  restorative  measures.  Even  then  hope  is  not  alto- 
gether lost,  for  the  individual  resistance  of  the  patient  may  save 
her.  A  person  whose  health  is  otherwise  good  rarely  dies  from 
postpartum  hemorrhage,  and  the  rapidity  with  which  blood  is  re- 
generated in  such  patients  is  truly  remarkable. 


CHAPTER  XYI 
EUPTURE  OF  THE  UTERUS 

ETIOLOGY 

The  structure  of  the  uterus  is  such  that  during  the  process  of 
birth,  it  propels  its  contents  along  the  path  of  least  resistance, 
which  is  the  cervical  portion.  Great  as  this  resistance  may  be, 
if  given  time,  it  will  yield,  and,  when  fully  opened,  will  permit 
the  child  to  pass.  Accompanying  the  dilatation,  and  as  a  part  of 
the  process,  the  outlet  to  the  uterus  undergoes  a  marked  structural 
attenuation.  In  some  respects  it  is  like  the  opening  of  a  sphincter 
muscle,  differing  from  such  action  chiefly  in  that  it  acts  more 
slowly.  If  now  the  forces  of  expulsion  are  too  great,  or  some  me- 
chanical obstruction  interposes,  the  uterus  continues  stretching 
until  it  reaches  its  limitation  at  some  weak  j^oint,  when  the  wall 
gives  way. 

There  is  less  resistance  in  the  wall  of  the  uterus,  and  a  greater 
tendency  to  tear,  in  subsequent  than  in  first  births.  About 
ninetj^  per  cent  of  the  ruptures  occur  in  multiparous  women. 

In  203  cases  rupture  was  due  to  the  following  causes,  or  at 
least,  the  foUoAving  were  the  prominent  factors  in  its  causation. 
(Mertz) : 

Pelvic  contraction  in  70  cases. 

Cross  birth  in  26  cases. 

Hydrocephalus  in  26  cases. 

Large  child  with  an  unfavorable  presentation 

of  the  head  in  18  cases. 
Scar  forrhation  in  the  birth  canal  in  10  cases. 
Pelvic  tumor  of  some  kind  in  3  cases. 
Cause  unknown  in  70  eases. 

While  it  probably  is  true  that  an  anatomic  disproportion  is 
primarily  responsible  for  rupture,  the  injury  will,  in  at  least 
one-third  of  the  cases,  be  the  direct  result  of  operative  violence; 

308 


RUPTURE   OF    THE    UTERUS 


309 


and  the  operation  most  frequently  responsible  is  that  of  version. 
The  Avedge-like  action  of  the  hand  and  arm  as  they  are  forced 
between  the  fetus  and  the  wall  of  the  uterus  in  search  of 
a  foot;  the  manual  correction  of  abnormal  presentations  of  the 
head    (face,  brow,   chin)  ;   the  employment  of  the  metreurynter, 


Fig.  174. — Rupture  of  the  gravid  uterus  (postmortem  section).  On  the  posterior  sur- 
face of  the  uterus  in  its  lower  segment,  the  head  of  the  fetus  is  seen  protruding  through 
a   rupture   in    the   wall.      (After   Zangemeister.) 


especially  if  the  uterus  is  not  able,  in  addition  to  its  own  con- 
tents, to  bear  the  increased  pressure  of  the  distended  bag-;  em- 
bryotomy, forceps,  or  even  an  examination,  if  pursued  with  vio- 
lence— any  one  of  these  procedures  may  cause  rupture. 

During  gestation  or  at  the  beginning  of  labor,  rupture  can  occur 


310 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


only  when  some  pathologic  condition  in  the  uterus  accompanies  the 
pregnancy,  when  degenerative  change,  marked  atrophy,  or  scar 
formation  have  greatly  impaired  the  elasticity  of  the  tissues. 
Hydrocephalus,  also,  may  be  responsible  for  rupture  early  in  labor 
since  the  presence  of  the  abnormally  large  head  has  already  served 
to  thin  out  the  lower  segment  to  a  dangerous  degree. 

Symptoms. — If  the  uterus  is  about  to  rupture,   symptoms   of 


Fig.    175. — Complete    rupture    of    the    uterus.       The    tear    is    through    the    lower    segment 
and  the  upper  part  of  the  cervix.      (Redrawn  from  Hammerschlag.) 


a  threatening  nature  are  often  to  be  observed.  The  rhythm 
of  labor  becomes  disturbed  by  the  unequal  and  futile  struggle  go- 
ing on,  the  pains  following  one  another  so  rapidly  that  no  interval 
of  rest  is  allowed  the  patient ;  the  abdomen  groAvs  rigid  and  sensi- 
tive to  touch,  especially  over  the  hypogastrium ;  and  the  pulse  be- 
comes rapid  and  small.  Occasionally,  the  fetal  parts  as  they  ap- 
proach the  surface  through  the  thinned  wall  of  the  uterus,  can  be 


RUPTURE    OF    THE    UTERUS 


311 


felt  with  unusual  distinctness,  the  round  ligaments  feel  like  cords, 
and  the  ring  of  Bandl  courses  high  over  the  abdomen. 

The  occurrence  of  a  rupture  is  generally  recognized  by  the 
patient  herself.  It  comes  like  a  blow,  and  is  accompanied  with 
severe  pain  and  hemorrhage.  The  advancing  part,  which  hereto- 
fore remained  fixed  in  the  pelvis,  now  becomes  movable  and,  if  the 
rupture  is  complete,  disappears  altogether.  Labor  ceases  at  once, 
and  the  woman's  condition  assumes  a  grave  aspect.    A  very  signifi- 


Fig.    176. — A   tear    through   the   cervicovaginal    commissure,    following   version    and    extrac- 
tion.     (Redrawn   from   Hammerschlag.) 

cant  sign  is  sometimes  to  be  made  out  with  the  hand.  Applied  to 
the  abdomen,  the  sudden  relaxation  of  the  tissues  and  the  ease  with 
which  fetal  parts  may  be  palpated,  are  quite  convincing  proof  that 
rupture  has  taken  place.  If  rupture  occurs  gradually,  labor  does 
not  stop  so  suddenly,  the  peritoneal  irritation  is  less  severe,  and  the 
advancing  part  does  not  recede.  Shock  and  anemia,  too,  are  less 
profound. 

A  laceration  of  the  uterus  almost  always  begins  in  the  lower 


312  MANAGEMENT    OF    THE   SERIOUS    COMPLICATIONS 

segment.  From  there  it  may  extend  upward  to  the  fundus  or 
downward  into  the  vagina.  It  may  take  place  in  the  anterior, 
posterior,  or  lateral  wall  of  the  uterus,  and  may  be  lengthwise, 
crosswise,  or  oblique  in  its  course. 

In  three-fourths  of  all  cases  of  rupture  the  tear  includes  all 
the  layers  of  the  uterine  wall ;  in  the  other  fourth  the  peritoneum 
over  the  rupture  remains  intact.  In  the  complete  form,  hem- 
orrhage takes  place  into  the  free  abdominal  cavity,  and  the  fetus 
and  placenta  either  protrude  through  the  rent,  or  are  entirely  ex- 
pelled into  the  abdomen.  In  the  incomplete  variet^^,  the  blood  be- 
comes extravasated  into  the  connective  tissue  under  the 
peritoneum,  forming  large  hematomata,  which  may  extend  to  the 
region  of  the  kidne}".  Through  the  entrance  of  air,  an  emphysema 
may  develop  in  the  same  way. 

The  localization  of  a  tear  depends  on  the  connection  it  has  with  a 
contiguous  organ,  especialh'  the  bladder,  which  is  frequently 
torn  into. 

DIAGNOSIS 

The  diagnosis  of  rupture  is  based  on  the  sudden  cessation  of 
labor,  the  intense  pain,  the  hemorrhage,  the  recession  of  the  fetal 
parts,  and  the  general  collapse  of  the  patient.  Further  proof  of 
rupture  is  to  be  found  in  the  altered  posture  of  the  fetus  and  the 
objective  changes  in  the  mother's  abdomen.  The  child  can  be 
palpated  with  astonishing  ease,  while  the  emptied  uterus  lies  as 
a  hard  tumor  close  beside  the  fetal  head.  Internally,  the  fetus  is 
found  wholly  or  partially  expelled  from  the  uterus,  the  lacerated 
margins  of  the  rupture  having  a  distinctly  jagged  outline.  In  mak- 
ing such  an  examination,  one  is  admonished  to  proceed  with  great 
precaution  in  order  not  to  tear  apart  the  still  intact  peritoneum, 
for  rough  handling  may  convert  an  incomplete  into  a  complete 
rupture. 

PROGNOSIS 

The  chief  danger  to  the  mother  comes  from  hemorrhage  and 
puerperal  peritonitis.  And  since  this  last  complication  is  more 
likely  to  occur  if  the  peritoneum  be  broken,  the  prognosis  is  worse 
in  the  complete  than  in  the  incomplete  rupture.     The  one  has  a 


RUPTURE  OF  THE  UTERUS  313 

mortality  of  about  seventy  per  cent,  the  other  aliout  fifty  per  cent. 
For  the  child,  the  outlook  is  exceedingly  bad,  especially  in  the 
spontaneons  complete  rupture  with  expulsion  of  the  fetus  into  the 
abdominal  cavity.     It  is  practically  always  fatal. 

The  prognosis  as  regards  the  subseciuent  condition  of  the  pelvic 
viscera  is  also  bad  if  the  reparations  are  accompanied  by  paramet- 
ric and  peritonitic  exudates.  The  consequent  adhesions  and  scar 
formations  make  it,  in  this  way,  quite  possible  for  the  uterus  to 
rupture  again  should  pregnancy  be  repeated. 

TREATMENT 

The  first  and  most  important  point  in  the  consideration  of  such 
injuries  is  prophylaxis.  In  every  obstetric  situation  that 
threatens  the  integrity  of  the  uterus  the  most  careful  and  pains- 
taking observations  should  be  made  in  order  not  to  overlook  the 
signs  of  impending  rupture.  If  rupture  seems  imminent,  im- 
mediate delivery  is  indicated ;  and,  when  possible,  the  child  should 
be  delivered  without  attempting  to  change  its  position,  version 
especially  being  very  dangerous  under  such  circumstances. 
Very  likely  some  form  of  embryotomy  will  have  to  be  performed. 
In  a  contracted  pelvis,  pubiotomy  and  cesarean  section  are  opera- 
tions that  merit  consideration. 

In  case  rupture  has  already  occurred,  delivery,  again,  is  the  thing 
to  undertake.  If  still  within  the  uterus,  the  child  may  be  ex- 
tracted by  the  feet,  with  forceps,  or  through  perforation  and 
cranioclasis,  all  depending  on  the  position  of  the  child  and  the  feasi- 
bility of  one  or  the  other  of  these  methods  being  carried  out.  If  it 
is  found  that  the  child  lies  partly  within  and  partly  without  the 
uterus,  it  may  still  be  possible  to  deliver,  especially  if  a  foot  can  be 
grasped  without  increasing  the  danger  of  extending  the  laceration. 
On  the  other  hand,  if  the  child  lies  completely  Avithout  the  uterus  in 
the  cavity  of  the  al)domen,  it  is  not  permissiljle  to  try  to  bring  it 
back  through  the  rupture,  first,  because  the  danger  of  infection  is 
too  great,  and,  second,  because  the  tear  in  the  uterus  is  likely  to  be 
extended.  The  safer  and  lietter  way  is  to  open  the  abdomen, 
deliver  the  fetus  and  placenta,  and  sew  up  tlie  rent  in  the  uterus. 
If  sepsis  does  iiot  supervene,  recovery  may  be  confidently  expected. 
Further  treatment  demands  absolute  rest  in  bed,  the  application  of 


314  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

an  ice  bag  to  the  abdomen,,  and  the  administration  of  opium  (tinc- 
ture of  opium,  10-15  drops,  t.  i.  d.,  for  two  days).  If  hemorrhage 
continues  after  the  child  has  been  removed,  particularly  if  its 
delivery  is  through  the  natural  passages,  the  vagina  is  opened  with 
a  speculum,  the  cervix  grasped  with  vulsella,  and  the  uterus 
packed  with  iodoform  gauze.  All  this  must  be  done  cautiously,  for 
fear  of  making  a  complete  rupture  out  of  one  that  is  incomplete, 
and  thus  greatly  complicate  the  situation.  For  a  few  hours  the 
fixation  forceps  may  be  left  in  place,  since  the  next  step  in  the 
efforts  to  stop  bleeding  may  require  the  ligation  of  the  uterine 
arteries;  and  to  have  the  vulsella  in  position  is  obviously  of  ma- 
terial advantage.  In  combating  hemorrhage,  should  it  continue 
after  tamponing  the  uterus,  it  will  be  found  helpful  to  lay  a  ring 
of  gauze  about  the  uterus  externally,  and  hold  it  there  firmly  with  a 
binder  or  with  a  bag  of  sand.  The  elastic  ligature  of  Momburg, 
already  referred  to  in  connection  with  postpartum  hemorrhage, 
may  similarly  be  of  service  in  temporarily  checking  the  flow  of 
blood.  Even  the  pressure  of  the  hand,  when  applied  direct!}^  over 
the  aorta,  serves  the  same  purpose.  One  should  not  forget  this,  and 
waste  precious  moments  adjusting  ligatures  and  bandages  when  a 
little  pressure  with  the  thumb  in  the  right  place  will  serve  the  pur- 
pose. As  soon  as  bleeding  has  been  brought  under  control,  at- 
tention should  be  given  to  the  anemia  and  its  relief.  (For  the 
treatment  of  Anemia,  see  page  302.) 

The  tampon  should  be  left  undisturbed  for  thirty-six  to  fortj^- 
eight  hours.  Danger  from  hemorrhage  is  practically  over  by  then, 
and,  if  the  patient  escapes  infection,  her  recovery  is  usually  rapid. 
Peritoneal  infection  is  not  greatly  to  be  feared  if  the  injury  is  of 
the  incomplete  form ;  but,  unfortunately,  one  does  not  ahvays  know 
the  extent  of  the  lesion  and  the  unwelcome  situation  sometimes  pre- 
sents itself  of  peritonitis  setting  in  after  the  patient  has  recovered 
from  the  earlier  dangers  from  shock  and  hemorrhage. 

Success  in  the  management  of  rupture  depends  a  great  deal  on 
where  the  patient  happens  to  be  when  the  accident  occurs.  In  her 
own  home,  without  immediate  and  competent  help,  it  becomes 
grave ;  in  a  well-appointed  hospital,  where  good  assistance  is  avail- 
able, the  outlook  is  far  from  hopeless. 

In  slight  lacerations  the  serosa  is  brought  together  with  a  con- 
tinuous suture  of  catgut,  or,  if  the  rent  is  Ifirge  enough  to  admit  of 


RUPTURE  OF  THE  UTERUS  315 

it,  the  wall  may  be  closed  in  layers  as  in  cesarean  section.  An  ex- 
tensive transverse  tear,  especially  if  it  involves  the  bladder,  may  re- 
quire amputation  or,  possibly,  complete  removal  of  the  uterus. 

After  all,  the  results  are  no  better  when  treated  by  section  than 
may  be  expected  when  only  the  tampon  is  used.  Indeed,  one  is 
hardly  justified  in  opening  the  abdomen  except  in  complete  rupture 
of  the  uterus,  and  perhaps  not  then  if  hemorrhage  can  be  con- 
trolled by  packing.  If  the  abdomen  must  be  opened  for  purposes 
of  delivery,  or  if  a  prolapse  of  the  intestines  can  not  be  reduced 
through  the  vagina,  or  the  rupture  involves  a  neighboring  organ, 
then  a  laparotomy  becomes  necessary.  Undoubtedly,  the  woman's 
best  interests  will  be  considered  if  the  cavity  of  the  uterus  is 
packed  as  recommended,  and  surgical  procedures  resorted  to  only 
when  they  become  positively  indicated.  A  spontaneous  rupture 
occurring  during  pregnancy  or  at  the  onset  of  labor,  would, 
obviously,  have  to  be  treated  intraabclominally. 


4 


CHAPTER  XVII 
LACERATIONS  OF  THE  CERVIX 

Lacerations  of  the  cervix  are  relatively  coimnon.  Indeed,  it  is 
hardly  possible  to  escape  them;  but  for  the  most  part  such  injuries 
are  not  extensive  enough  to  require  surgical  attention.  The  more 
serious  ones  come  from  rapid  dilatation,  whether  this  be  due  to  the 
rapid  passage  of  the  child,  the  forcible  introduction  of  the  ob- 
stetrician's hand,  divulsion  Avith  powerful  instruments,  or  the  im- 
proper use  of  hydrostatic  bags.  The  tear  is  most  likely  to  occur 
if  the  tissues  themselves  have  lost  their  elasticity,  that  is,  if  their 
normal  quality  of  stretching  without  tearing  has  become  impaired. 
Placenta  previa,  for  example,  can  so  alter  the  character  of  the 
cervix  in  this  respect  that  it  will  give  way  under  what  otherwise 
would  be  harmless  force. 

Lacerations  of  the  cervix  ai'e  almost  always  longitudinal,  ex- 
tending along  one  or  both  sides  of  the  canal.  Tears  which  include 
only  the  intravaginal  part  of  the  cervix,  ending  short  of  the  vault, 
have  little  significance,  since  no  large  vessels  are  involved,  and  the 
danger  from  infection  extending  upward  into  the  pelvis  is  slight. 
But  lacerations  which  reach  into  the  parametrium  become  serious, 
even  dangerous  to  life. 

The  hemorrhage  from  a  laceration  generally  makes  its  first  ap- 
pearance immediately  after  the  child  is  born,  its  extremities  often 
being  covered  with  Ijlood.  Until  then  the  advancing  part  prevents 
by  pressure  any  serious  bleeding  taking  place.  The  blood  is  bright 
red,  and  flows  continuously,  although  the  uterus  remains  con- 
tracted. 

The  bleeding  is  not  always  external.  It  may  extend  into  the 
broad  ligaments,  and  there  form  hematomata;  or  a  thrombus  may 
develop  at  the  point  of  rupture  only  to  give  way  in  the  puer- 
perium. 

A  laceration  may  be  so  extensive  as  to  involve  the  ureters  and 
cause  fistula?,  uterovaginal,  or  even  uteroureteral. 

316 


LACERATIONS    OP    THE    CERVIX 


517 


Parametric  exudates,  scar  formations,  malpositions,  and  other 
gynecologic  conditions  often  date  their  beginning  from  a  cervical 
laceration  accompanying  childbirth. 

In  determining  the  extent  of  a  laceration,  very  little  informa- 
tion can  be  gained  from  palpation  alone;  actual  inspection  of  the 
parts  must  be  made. 


Fig.    177. — Suturing  the  lacerated  cervix. 

Repairing-  the  Torn  Cervix. — A  tear  that  is  not  accompanied  by 
hemorrhage,  requires  no  treatment;  one  that  is,  should  be  sutured 
or  packed  at  once.  In  general  practice  packing  is  easier  than 
suturing,  and  in  most  cases  it  is  quite  sufficient.  Even  a  laceration 
into  the  supravaginal  tissue  had  better  be  treated  in  this  way  unless 
one  has  hospital  facilities  at  hand.  Repair  (Fig.  177)  of  an  injury 
of  this  character  is  made  as  follows:     After  careful  but  rapid 


318  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

disinfection,  the  cervix  is  exposed  by  speculum,  grasped  with 
vulsella  and  brought  to  the  introitus.  The  vesicouterine  fold  is 
separated,  and  the  bladder  pushed  up  out  of  the  way,  much  the 
same  as  in  proceeding  with  vaginal  cesarean  section,  already  de- 
scribed. The  tear  is  now  exposed  in  its  entirety,  and  closed  with 
catgut.  If  there  is  bleeding  from  the  uterine  arteries,  their  liga- 
tion becomes  necessary.  Closing  the  vaginal  wall  completes  the 
operation. 

PROGNOSIS 

The  prognosis  is  always  serious  when  the  laceration  extends  into 
the  supravaginal  tissue,  where  important  vessels  are  likely  to  be 
torn.  The  simpler  injuries  are  not  accompanied  by  much  danger; 
but,  inasmuch  as  one  can  never  know  hoAv  extensive  a  laceration 
may  .be  without  investigation,  it  is  wise  to  examine  the  cervix  after 
every  delivery.  The  influence  of  infection,  too,  must  be  considered 
in  the  prognosis,  for  very  often  puerperal  morbidity,  subinvolution, 
and  permanent  ill  health  may  follow  from  it. 


CPIAPTEE  XVIII 
LACERATIONS  OF  THE  VAGINA 

ETIOLOGY 

Carried  beyond  its  limitations,  the  stretched  and  attenuated 
vagina,  like  other  parturient  structures,  will  give  way.  The  separa- 
tion generally  takes  place  at  its  junction  with  the  uterus,  either 
in  front  or  behind  the  cervix,  but  it  can  be  so  extensive  as  to  tear 
loose  in  its  whole  circumference.  Brief  mention  of  such  a  case  fol- 
lows: 

Some  years  before  I  saw  her,  an  ItaHaii  woman  underwent  an  ordeal  so 
serious  that  a  complete  atresia  of  the  vagina  followed  her  delivery.  Just  what 
.occurred  during  labor,  I  am  unable  to  say.  From  her  husband  I  learned  that 
after  a  midwife  and  several  doctors  had  exhausted  themselves  in  their  attempts 
to  deliver  her,  she  was  taken  to  the  hospital  where  an  embryotomy  was  per- 
formed. In  all  probability  the  uterovaginal  attachment  was  torn  loose,  for 
at  the  time  I  first  saw  her  the  vault  was  sealed  over  so  completely  with  scar 
formations  that  no  opening  into  the  uterus  could  be  found,  nor  could  one  be 
made  out  from  within  the  abdomen  when  she  was  operated  on  later. 

The  forces  responsible  for  lacerations  of  the  vagina  are  the  same 
as  cause  rupture  of  the  uterus  and  severe  tears  of  the  cervix;  and, 
as  in  those  injuries,  the  seriousness  of  the  laceration  depends  largely 
on  the  degree  of  peritoneal  involvement.  Falling  short  of  this 
structure,  a  tear  in  the  vagina  has  few  serious  aspects.  Occurring 
in  the  course  of  a  spontaneous  birth,  lacerations  of  the  vagina  have 
no  particular  significance.  It  is  only  when  produced  through  for- 
cible introduction  of  the  hand  or  violent  operative  procedures  that 
they  become  serious.  Certain  movements  in  delivering  with  for- 
ceps, such  as  oscillation  and  rotation,  made  by  the  accoucheur  in 
his  efforts  to  dislodge  an  obdurate  fetus,  or  the  improper  introduc- 
tion of  the  forceps  blades,  are  accountable  for  much  of  the  harm 
done.  A  bungling  operator  may  even  force  the  blades  through  the 
vagina  into  the  peritoneal  cavity. 

319 


320  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

The  part  of  the  canal  most  likely  to  suffer  injury  is  the  outlet,  the 
consideration  of  Avhich  Avill  be  taken  up  a  little  further  on. 

Severance  of  the  bony  arch,  as  in  pubiotomy,  is  sure  to  be  fol- 
lowed by  more  or  less  trauma,  not  only  of  the  vagina,  but  also  of 
the  bladder  and  urethra. 

Venous  stasis,  due  to  long-continued  pressure  of  the  head,  may 
be  followed  in  rare  instances  by  laceration  of  the  vessels  with  for- 
mation of  hematomata. 

SYMPTOMS 

The  overstretched  and  torn  vagina  gives  rise  to  symptoms  similar 
to  those  of  ruptured  uterus,  differing  only  in  their  gravity;  the 
pain  ceases  more  gradually,  the  bleeding  is  less  profuse,  the  collapse 


Fig.    178. — The  claw   forceps. 

is  less  marked.  As  in  the  other  injury,  the  child  may  escape  into 
the  abdominal  cavity.  The  presence  of  urine  and  feces  in  the 
wound  furnishes  unmistakable  evidence  that  the  bladder  and 
rectum  have  become  torn. 

Where  lacerations  are  directly  due  to  the  use  of  instruments, 
hemorrhage  is  generally  perceived  at  once,  but  in  spontaneous 
tears  the  bleeding  may  not  appear  until  after  the  child  has  been 
delivered ;  or,  instead  of  showing  externally,  the  hemorrhage  may 
take  place  into  the  paravaginal  tissue,  with  development  of  hemato- 
mata. Such  tumors,  besides  being  very  painful,  may  be  so  ex- 
tensive as  to  reduce  considerably  the  lumen  of  the  canal. 


LACERATIONS    OF    THE    VAGINA  321 

DIAGNOSIS 

If  blood  first  appears  during  an  operative  procedure,  one  is  led 
to  eonelude  that  the  operation  itself  is  the  cause  of  the  hemorrhage ; 
if  it  appears  only  upon  the  delivery  of  the  child,  it  is  presumed  to 
be  due  to  injury  of  the  cervix.  One  is  not  always  able  to  learn  the 
source  of  hemorrhage  b.y  palpation  alone ;  indeed,  it  is  often  neces- 
sary, and  generally  more  satisfactory,  at  once  to  inspect  the  parts 
through  a  speculum. 

When  the  laceration  extends  into  the  bladder  or  rectum,  there 
is  immediate  discharge  of  urine  or  feces  into  the  vagina.  The 
opening  may  be  large  enough  to  admit  the  finger,  in  which  case  the 
diagnosis  is  made  easy.  In  other  cases  a  speculum  will  be  needed 
to  expose  the  torn  surfaces  before  one  can  say  whether  it  is  urine  or 
feces  that  escapes.  Later,  after  some  days  or  weeks,  the  more 
delicate  means  of  diagnosis,  by  cystoscopy  may  be  employed ;  or  the 
older,  but  quite  satisfactory,  method  of  injecting  milk  into  the 
bladder  and  observing  th©  point  of  its  escape,  may  be  tried.  Exact 
diagnosis,  however,  would  better  be  deferred  until  the  puerperium 
is  well  over,  when  the  tissues  can  be  put  on  the  stretch  and  the 
damaged  structures  thoroughly  inspected. 

A  rare  laceration  of  the  retrovaginal  septum  may  come  from  the 
unwarranted  practice  of  introducing  the  finger  into  the  rectum  to 
press  out  the  head. 

TREATMENT 

Careful  inspection  is  made  with  the  help  of  a  speculum  and  a 
lateral  retractor.  All  spurting  vessels  are  clamped  and  ligated, 
and  the  torn  edges  brought  together  with  catgut.  If  the  laceration 
extends  far  up  the  canal,  pressure  on  the  fundus  from  the  outside 
is  a  harmless  means  of  bringing  the  wounded  area  into  better  view. 
If  the  bladder  or  rectum  is  involved,  their  reparation  requires 
better  facilities  and  more  competent  assistance  than  otherwise 
would  be  necessary.  Small  openings  of  the  bladder  frequently 
close  of  themselves  if  the  organ  is  kept  quiescent,  as  may  be  done 
by  the  introduction  of  a  self-retaining  catheter.  A  cure  for  fistula 
should  not  be  undertaken  before  the  tissues  have  returned  to  nor- 
mal, which  only  occurs  after  several  weeks  or  months. 


322  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

If  one  is  not  able  to  control  hemorrhage  by  ligation,  he  should 
pack  the  uterus,  as  well  as  the  vagina,  with  gauze. 

A  hematoma  large  enough  to  cause  obstruction  should  be 
evacuated. 

PROaNOSIS 

The  prognosis  is  generally  good,  since  the  lacerations  tend  to 
heal  readily.  In  the  more  serious  forms,  as  when  the  vagina  is 
torn  loose  from  the  uterus,  the  prognosis  is  no  less  grave  than  in 
rupture  of  the  uterus  itself.  Infection  is  followed  by  pus  forma- 
tion and  inflammation,  which  may  extend  into  the  paravaginal  and 
parametric  tissue,  leaving  in  its  Avake  scar  formations  and  other 
gynecologic  ailments  to  be  fastened  on  the  patient. 


CHAPTER  XIX 
PRESSURE  INJURIES  OF  THE  CERVIX  AND  VAGINA 

DIAGNOSIS 

A  pressure  injury  can  not  be  diagnosed  at  the  time  of  labor. 
An  increasing  edema  of  the  cervix  with  blood-stained  urine,  fol- 
lowing a  prolonged  arrest  of  the  head,  points  toward  it  with  con- 


Fig.  179. — Illustrates  how,  in  prolonged  arrest  of  the  head,  pressure  against  the  bony 
prominences  of  the  pelvis  may  be  the  cause  of  local  necrosis  of  the  intervening  structures, 
and  the  development   of  fistulae. 

siderable  certainty,  and  one  can  only  conclude  that  injury  is  im- 
pending from  basing  his  fears  on  experience.  Later,  when  urine 
or  feces  makes  its  appearance  in  the  vagina,  a  positive  diagnosis  be- 
comes easy.  If  the  pressure  involves  a  large  area  of  the  anterior 
wall,  so  that  a  considerable  portion  of  the  vaginal  support  is  lost, 
a   vaulting  downward   and   forward   of   the   bladder   takes  place 

323 


324  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

through  the  opeiiiiig,  showing  itself  as  a  reddish  tumor  at  the  vulva. 
In  some  instances  such  a  displacement  may  be  so  great  as  to 
bring  the  ureters  into  view. 


TREATMENT 

In  a  prolonged  labor  frequent  examinations,  both  external  and 
internal,  should  be  made,  in  order  to  determine  whether  the  head 
remains  fixed ;  for  if  it  does,  and  edema  of  the  cervix,  bloody  urine, 
and  swelling  of  the  ^'ulva  follow,  the  condition  must  be  relieved  or 
pressure  necrosis  will  result.  The  injury  having  occurred,  it  is 
best  to  defer  reparation  for  at  least  two  months.  This  is  neces- 
sary in  order  to  give  nature  time  to  complete  her  part  of  the  re- 
generative process. 

PROGNOSIS 

As  far  as  life  is  concerned,  the  prognosis  is  good ;  but  as  regards 
the  parts  themselves  the  outlook  is  not  particularly  promising. 
Instead,  prolonged  illness,  repeated  operations,  severe  scar  forma- 
tions, and,  eventually,  chronic  invalidism  are  some  of  the  unwel- 
come sequelae  to  be  dreaded  in  injuries  of  this  nature. 


CHAPTER  XX 
INJURIES  OF  THE  VULVA  AND  PERINEUM 

ETIOLOGY 

While  all  the  structures  of  the  birth  canal  are  exposed  to  injury, 
the  parts  most  likely  to  suffer  are  those  in  and  around  the  perineum 
(Fig.  180).  Apparently  the  genital  cleft  is  inadequate,  and  one 
never  ceases  to  marvel  that  a  child  can  pass  through  it  without  do- 
ing harm  to  its  component  structures ;  and,  for  that  matter,  it  can 
not.  The  fact  that  subsequent  births  are  shorter  and  easier  than  the 
first  is  proof  that  the  tissues  have  suffered  from  the  process,  and 
that  their  competency  thereby  has  become  impaired.  However, 
it  is  not  intended  to  dwell  on  the  remote  effects  of  parturition; 
only  its  immediate  and  demonstrable  lesions  now^  concern  us. 

The  causes  of  injury  to  the  vulva  and  perineum  are  much  the 
same  as  the  causes  of  injury  to  the  cervix  and  vagina.  Especially 
in  first  births  is  the  contracted  introitus  liable  to  be  torn.  The  ra- 
pidity Avith  which  birth  takes  place  is  also  a  factor.  The  tissues 
themselves,  too,  vary,  both  from  age  and  individually.  Their  elas- 
ticity may  become  impaired  through  pathologic  alteration,  such  as 
scar  formations,  condylomata,  edematous  swelling,  kraurosis,  etc. 
Indirectly,  an  abnormal  pelvic  inclination,  or  a  greatly  contracted 
pubic  arch,  each  of  which  gives  the  head  an  altered  direction,  may 
be  responsible;  and  while  an  introital  injury  may  be  spontaneous, 
there  is  no  doubt  but  an  instrumental  delivery  adds  to  the  dan- 
ger. Much  depends,  of  course,  on  the  skiU  and  judgment  of  the 
operator ;  but  the  introduction  of  the  hand,  the  extraction  of  the 
breech,  the  freeing  of  the  arms,  the  delivery  of  the  after-coming 
head,  the  use  of  forceps,  in  fact  any  of  these  procedures,  whether 
skillfully  executed  or  not,  increases  the  risks. 

COURSE  AND  SYMPTOMS 

Most  of  the  aforementioned  injuries  befall  the  structures  of  the 
pelvic  floor  and  perineum.    The  giving  w^ay  of  the  latter  may  be  ob- 

325 


326 


MANAGEMENT   OE    THE    SERIOUS    COMPLICATIONS 


served  as  it  takes  place,  but  the  giving  way  of  the  former  is  not 
so  easily  made  out;  and  it  is  not  possible  when  made  out  to  say  how 
extensive  the  damage  may  be  until  later. 


Fig.    ISO. — The  levator  ani  muscle.      (From   Doderlein   and   Kronig.) 


A  laceration  is  spoken  of  as  complete  when  the  rupture  includes 
the  external  sphincter  of  the  anus,  and  incomplete  when  it  stops 
short  of  it.  Of  the  latter  there  can  be  many  degrees, — from  the 
smallest  tear  of  the  fourchette  to  a  rupture  of  all  the  structures 


INJURIES   OF    THE    VULVA    AND    PERINEUM  327 

down  to  the  sphincter.    The  complete  tear  may  also  include  the  an- 
terior rectal  wall. 

The  symptoms  of  introital  trauma,  other  than  hemorrhage,  are 
slight.  A  burning  sensation  will  generally  be  complained  of,  but 
very  much  the  same  pain  may  come  from  distention  alone.  And  as 
for  the  hemorrhage,  there  is  usually  very  little  unless  the  lacer- 
ation extends  to  the  region  of  the  clitoris,  or  involves  large  vari- 
cosities of  the  vulva.  In  tears  that  include  the  sphincter  ani  there 
follow  involuntary  expulsion  of  tlatus  and  feces  per  vaginam. 

DIAGNOSIS 

After  every  delivery  the  whole  lower  birth  canal  should  be  care- 
fully examined.  To  do  this  to  the  best  advantage  the  patient  should 
be  placed  crosswise  on  the  bed  with  good  light  coming  over  the 
operator's  shoulder.  With  sterile  gauze  the  parts  are  sponged,  in- 
spected, and  palpated  for  injuries.  Besides  noting  the  state  of  the 
perineum  itself,  three  things  should  satisfactorily  be  demonstrated : 
(1)  the  source  and  amount  of  bleeding,  (2)  the  condition  of  the' 
vaginal  wall,  and  (3)  the  competency  of  the  sphincter  ani  muscle. 
This  last  is  determined  by  passing  the  exploring  finger  (cotted)  in- 
to the  rectum. 

PROPHYLACTIC  TREATMENT 

Reducing  the  Speed  of  Expulsion. — When  the  forces  of  labor 
appear  to  be  driving  the  child  forward  with  too  great  speed,  one 
way  of  safeguarding  the  perineum  is  by  regulating  or  checking 
these  forces,  which  is  best  accomplished  with  chloroform  judiciously 
employed. 

Supporting  the  Perineum  Manually. — By  applying  the  hand  ex- 
ternally, the  perineum  is  reinforced  and  the  tissues  supported.  At 
the  same  time  the  lateral  waDs  of  the  canal,  as  well  as  their  median 
insertion,  are  given  time  to  retract,  and  their  dislocation  forward 
is  prevented. 

The  Observance  of  Correct  Mechanism. — It  is  a  w  ell-known 
mechanical  principle  in  obstetrics  that  the  fetus  naturally  assumes 
the  most  favorable  posture,  and  moves  along  the  path  of  least  resist- 
ance.   In  a  normal  bii'th,  therefore,  such  adaptation  is  spontaneous 


328 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


and  requires  little  superyision.  So  far  as  the  position  of  the  pa- 
tient is  concerned,  these  principles  can  be  applied  whether  she  lie 
on  the  back  or  the  side.  The  side  position  is  recommended  in  spon- 
taneous deliveries  for  the  reason  that  the  parts  may  more  favor- 
ably be  inspected,  and  both  hands  employed  to  advantage.    Abdom- 


Fig.   181. — Supporting  the  perineum  in  the  lateral  position. 

inal  pressure,  too,  can  be  somewhat  better  regulated  and  con- 
trolled. Usually,  the  position  is  not  assumed  until  shortly  before 
the  end  of  labor,  which  may  mean  in  one  case  only  a  iew  minutes 
and  in  another  perhaps  an  hour.  If  the  woman  has  borne  other 
children,  she  is  turned  on  the  side  when  the  head  becomes  visible 


INJURIES    OF    THE    VULVA    AND    PERINEUM 


329 


at  the  vulva;  but,  if  she  is  in  Her  first  labor,  it  will  be  soon  enough 
to  take  the  lateral  position  if  she  waits  until  in  the  interim  of  a 
pain  the  head  remains  on  the  pelvic  floor.  As  to  which  side  the  pa- 
tient shall  be  turned,  varies  with  the  position  of  the  child.  Theo- 
retically, she  should  lie  on  the  left  side  in  left  positions  of  the  head, 
and  on  the  right  side  in  right  positions  of  the  head ;  but  practically 
it  makes  little  difference  on  which  side  she  lies.  In  fact  some  ob- 
stetricians prefer  the  left  side  no  matter  in  what  position  the  head 
may  be. 


/«V| 


-  / 


X 


Fig.   182. — Supporting  the  perineum  in  the  dorsal  position. 

Ill  delivering  on  the  side,  the  buttocks  are  brought  close  to  the 
edge  of  the  bed  with  the  legs  and  thighs  flexed.  The  accoucheur 
sits  or  stands  with  his  back  toward  the  head  of  the  bed.  After  the 
usual  preparations  for  delivery  have  been  made,  the  patient  may 
be  covered  with  a  sterile  sheet,  which  need  not  be  lifted  before  the 
head  reaches  the  vulva  and  not  then,  if  the  delivery  is  normally 
easy.    With  a  sterile  dry  towel,  some  prefer  a  hot  wet  one,  the  pre- 


330 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


senting  head,  the  vulva,  the  perineum,  and  the  anus  are  covered, 
and  the  open  hand  applied  to  the  outside. 

When  the  head  of  the  child  is  about  to  pass  the  introital  ring,  an 
assistant  lifts  the  patient's  knee.     This  enables  the  accoucheur  to 


Fig.    183. — Episiotomy.      Severing   the    introitus. 


prevent  with  one  hand  the  head  from  advancing  too  rapidly  while 
the  other  is  left  free  to  operate  in  the  region  of  the  perineum,  where 
he  may  with  the  thumb  and  fingers  favor  rotation  or  support  the 
taut  tissues  (Fig.  181.) 

It  is  proper  in  this  connection  to  add  that  the  technic  of  "sup- 


INJURIES    OF    THE    VULVA    AND    PERINEUM 


331 


porting  the  perineum"  is  not  a  clearly  defined  procedure.  It  may 
mean  manipulation  to  one  operator  and  chloroform  to  another.  The 
essential  thing  is  time,  to  let  nature  take  its  course,  with  just 
enough  supervision  to  see  that  the  tissues  are  not  strained  beyond 
what  they  can  stand.  Anesthesia  is  one  of  the  greatest  adjuncts 
to  the  obstetrician  when  the  head  is  moving  dangerouj-'ly  fast  and 
delay  is  cejired.     On  the  whole,  chloroform  is  quicker  and  more 


Fig.   184. 


-Topography    of    the    pelvic    floor    and    introitus.       (Redrawn    from    Doderlein 
and    Kronig's    Operative    Gynecology.) 


lasting  in  its  effect  than  ether ;  but  the  latter  is  known  to  be  safer 
and  somewhat  more  stimulating.  Neither  is  accompanied  by  ill  ef- 
fects when  given  to  the  obstetric  degree  of  narcosis. 

While  the  lateral  position  is  often  preferred,  the  dorsal  position 
in  most  eases  is  satisfactory,  especially  in  the  multipara  with  a  re- 
laxed outlet.  Standing  or  sitting  by  the  patient's  side,  if  she  lie 
lengthwise  on  the  bed,  or  facing  her  if  crosswise,  one  hand  is  laid 
over  the  vertex,  the  other  supports  the  perineum  (Fig.  182).    This 


332  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

is  also  the  more  favorable  position  of  the  two,  lateral  and  dorsal,  if 
much  difficulty  is  experienced  in  the  delivery  of  the  shoulders. 

If  one  is  compelled  to  interfere  before  the  tissues  have  been 
stretched,  and  especially  if  they  are  rigid  and  unyielding,  a 
colpeurynter  of  moderate  size  may  be  drawn  several  times  through 
the  parts.  If  it  appears  unavoidable  or  improbable  that  the  peri- 
neum will  escape  laceration,  a  prophylactic  vaginoperineal  incision 
is  indicated.  With  a  strong  pair  of  straight  scissors  a  cut  is  made 
at  one  side  of  the  middle  line  in  the  direction  of  the  tuber  ischii 
(Fig.  183).  AVith  the  first  snip  of  the  scissors  the  skin  is  usually 
the  only  part  cut,  exposing  the  white  glistening  fascia  beneath. 
A  second  bite  includes  the  fascia  and  the  trauversus  perinei  and 
sphincter  vaginae  muscles  (Fig.  184).  The  length  of  the  incision 
should  be  individualized,  but  it  is  better  to  make  it  a  little,  too 
long  than  too  short ;  otherwise  it  serves  the  undesirable  purpose 
of  being  a  starting  point  for  an  extensive  tear.  The  section 
serves  a  double  purpose.  First  and  foremost,  it  prevents  a  com- 
plete tear  of  the  sphincter  ani ;  and,  second,  it  provides  room  for 
the  carrying  out  of  the  operative  procedures,  particularly  the 
vaginal  cesarean  section. 

REPARATION 

To  allow  healing  without  suturing  ends  in  functional  incompe- 
tence, and  is  generally  followed  by  abnormalities  that  furnish 
many  of  the  regrettable  consequences  of  childbearing.  The  com- 
plete tear  is  accompanied  by  the  involuntary  escape  through  the 
vagina  of  intestinal  gases  and  feces,  a  most  intolerable  condition. 
Repair  also  becomes  necessary,  sometimes,  because  of  the  arterial 
hemorrhage  which  may  follow  the  laceration. 

The  following  instruments  are  required :  needles,  needle  holder, 
tissue  forceps,  scissors,  and  two  or  three  artery  clamps.  For  sutur- 
ing, material  must  be  used  that  Avill  hold  the  parts  in  position  for  at 
least  five  or  six  dajs.  Catgut  sometimes  fails  to  do  this,  and  there- 
fore does  not  meet  the  requirements  as  well  as  a  nonabsorbable 
material  such  as  silkworm.  Besides  instruments  and  sutures,  a 
good  supply  of  sterile  gauze  sponges  will  be  needed. 

Shall  the  patient  be  anesthetized?  So  much  depends  on  the  in- 
dividual case  that  no  fixed  rule  can  be  established.     She  must. 


INJURIES    OF    THE   VULVA   AND    PERINEUM  333 

however,  remain  quiet  while  the  stitches  are  being  placed,  and  un- 
less she  can  do  this  it  is  better  to  give  an  anesthetic.  Very  often 
the  parts  are  so  benumbed  from  the  stretching  they  have  under- 
gone that  one  or  two  stitches  can  be  placed  without  causing  much 
additional  pain.  In  case  the  injuries  should  be  more  extensive 
than  is  apparent  from  casual  inspection,  it  is  more  satisfactory  to 
have  the  patient  narcotized  while  the  manipulations  of  examination 
and  suturing  are  going  on. 

If  the  tear  is  well-defined,  sutures  may  be  introduced  before  the 
placenta  comes  aAvay,  tying  being  deferred  until  afterward.  Com- 
monly, repairs  are  not  undertaken  before  the  third  stage  of  labor 
is  over,  and  there  are  those  who  advocate  delay  still  longer,  even 
to  five  and  six  days  postpartum.  One  reason  for  postponement  is, 
that  oftentimes  labor  comes  to  an  end  at  an  hour  when  light  is  poor 
and  the  facilities  for  doing  painstaking  work  are  bad.  Another, 
and  not  .altogether  inadequate,  reason  is,  that  both  patient  and 
physician  may  be  too  spent  with  the  severity  of  the  case  to  under- 
take at  once  any  further  operative  procedure.  Perhaps  the  best 
reason  for  waiting,  however,  is  that,  after  twenty-four  to  forty- 
eight  hours,  the  recessional  changes  will  have  so  altered  the  rela- 
tions of  the  parts  that  what  seemed  an  extensive  injury  immediately 
after  delivery  may  now  appear  of  less  consequence.  At  any  rate, 
the  laceration  can  be  outlined  more  accurately.  Personally,  I  am 
of  the  opinion  that  it  is  an  advantage  to  repair  the  injury  as  soon 
as  it  occurs,  providing  none  of  the  conditions  referred  to  above, 
such  as  poor  light,  fatigue,  or  inadequate  assistance,  makes  it  im- 
possible for  the  surgeon  to  do  the  Avork  properly. 

The  Incomplete  Tear  of  the  Perineum. — The  patient  is  brought 
to  the  edge  of  the  bed  or  placed  on  the  operating  table,  the  thighs 
flexed  and  the  knees  supported.  The  extent  of  the  injury  is  de- 
termined, and  all  bleeding  arteries  clamped  and  ligated. 

The  first  suture  is  introduced  at  the  upper  angle  of  the  injury. 
This  point  is  brought  fairly  well  into  view  by  spreading  the  poster- 
ior wall  of  the  vagina  with  the  index  and  second  fingers  of  the  left 
hand;  but  to  have  the  anterior  wall  held  up  by  a  retractor  in  ad- 
dition is  a  marked  advantage.  A  very  useful  device  for  exposing 
the  surfaces  to  be  united,  and  for  holding  the  vulva  apart  while  the 
sutures  are  being  placed,  is  the  instrument  designed  by  Dr.  Gelpi 
(Fig.  185). 


334 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


The  continuous  suture  is  of  utility'  in  bringing  edges  together, 
but  is  of  doubtful  value  when  the  deeper  structures  are  to  be 
united;  and,  if  such  a  suture  is  of  catgut,  a  further  objection  can 
l)e  raised  that  not  always  is  its  resistance  to  absorption  to  be  relied 
upon.  If  it  gives  way  at  one  point,  the  whole  stitch  becomes  use- 
less.     Interrupted   sutures,    therefore,    are   to   be   preferred.      It 


Fig.    185. — Exposing  the  lacerated  area  with   Dr.    Gilpi's   forceps. 

may  take  a  little  longer  to  introduce  them,  but  they  are  more 
dependable. 

Beginning  at  the  upper  angle,  the  vaginal  tear  is  closed  as  far 
as  the  fourchette.  If  the  laceration  extends  into  both  sulci,  both  are 
sutured.  Many  complicated  methods  for  bringing  the  torn  peri- 
neum together  have  been  devised,  but  the  simpler  Avays  are  satisfac- 


INJT^RIES    OP    THE    VULVA    AND    PERINEUM 


335 


tory,  and  no  others  will  be  described.  The  one  thing  to  bear  in 
mind  is,  that  the  needle  must  be  carried  to  the  bottom  of  the  tear ; 
otherwise  an  open  space  will  be  left,  which  is  not  only  unfavorable 
for  union,  but  invites  pathogenic  activity  (Fig.   186).     In  deep 


Fig.    186. — Repairing    the    lacerated    perineum     (incomplete    tear).       The    three    upper    su- 
tures  may  be  of  catgut,   but  the   three   lower   ones   should   be   of   silkworm. 


lacerations  of  the  pelvic  floor  it  is  good  practice  to  introduce  a 
few  buried  sutures  to  make  sure  that  the  torn  muscles  and  fascia  are 
again  brought  together.  Finally,  the  skin  surface  is  closed  with  a 
continuous  suture  of  catgut. 


336      "  MAXAGEIUEXT    OF    THE    SERIOUS    COMPLICATIOXS 

Obviously,  a  Avouncl  in  this  region  is  exposed  to  unfavorable  con- 
ditions for  healing  because  of  the  discharges  and  the  difficulty  of 
applying  protective  dressings.  Some  attempt,  however,  should  be 
made  to  preserve  the  parts  from  contamination.  After  the  sutures 
have  been  placed,  the  surrounding  parts  are  thoroughly  cleansed 
and  dried,  and  the  perineum  dusted  with  aristol  or  other  water- 
proof powder.  An  absorbent  pad  is  then  placed  over  the  ^Tilva, 
and  the  knees  are  kept  together.  Subsecjuently  the  parts  should  be 
disturbed  as  little  as  possible.  Even  the  external  douche  may  be 
omitted  for  a  few  days,  and  the  bowels  left  inactive.  The  bladder 
may  be  emptied  by  catheterization.  On  the  foui*th  day  the  patient 
receives  a  purge  of  castor  oil,  to  be  repeated  every  second  or  third 
day.    By  the  eighth  to  the  tenth  day  healing  is  complete. 

The  Complete  Tear. — If  the  laceration  extends  through  the 
sphincter,  repair  becomes  somewhat  more  complicated;  Init  with 
good  light  and  proper  assistance  it  is  not  particularly  difficult.  In 
closing  the  bowel  suturing  is  begun  at  the  highest  point  of  rupture 
and  continued  do^m  to  the  anal  orifice.  The  last  stitch  is  near  the 
mucocutaneous  junction  (Fig.  187).  In  placing  these  stitches  one 
is  particular  not  to  include  the  mucous  membrane  of  the  rectum. 
first,  because  it  might  open  a  way  to  infection,  and,  second,  the  for- 
mation of  a  fistula  will  occasionally  result.  A  series  of  these  in- 
terrupted buried  sutui-es,  about  0.5  cm.  apart,  when  placed  in  po- 
sition, converts  a  complete  into  an  incomplete  tear,  the  further  re- 
pair of  which  is  the  same  as  has  been  described  under  that  caption. 
The  after-treatment  is  essentially  the  same  as  lacerations  of  lesser 
degree,  except  that  the  bowels  are  left  quiescent  for  a  longer  period. 
A  purge  is  not  given  before  the  sixth  day.  Until  then  the  diet 
should  be  so  modified  that  feces  are  not  likely  to  be  formed  in  the 
rectum,  even  suppressing  the  desire  to  stool  by  administration  of 
opium,  ten  drops  of  the  tincture,  several  times  a  day. 

The  Central  Tear. — The  bridge  of  tissue  in  front  is  first  cut. 
This  makes  an  incomplete  or  a  complete  tear  of  the  injury,  as  the 
case  may  be.  which  is  then  repaired  after  the  manner  already  de- 
scribed. 

The  Episiotomy  Wound. — -The  episiotomy  wound  assumes,  after 
delivery,  the  most  confusing  form.  When  the  incision  is  made, 
the  introital  ring  is  greatly  stretched  by  the  child's  head.  With 
the  distending  object  gone,  the  wound  becomes  elongated  at  right 


INJURIES    OF    THE    \^JLVA    AXD    PERINEUM 


337 


angles  to  the  section;  and,  unless  one  considers  carefully  the  nat- 
ural relations,  the  mistake  may  be  made  of  closing  the  wound  in  a 
way  to  leave  the  vulva  gaping  and  distorted.  The  placing  of  the 
sutures,  especially  the  first  one,  therefore,  is  most  important  (Fig. 
188).    Beginning  at  the  mucocutaneous  junction,  the  needle,  which 


Fig.  187. — Repairing  the  lacerated  ])eriiieu:ii  (complete  tear).  The  torn  sphincter  is 
first  brought  together  with  buried  interrupted  catgut  sutures.  This  converts  the  complete 
into    an   incomplete    laceration,    which   is    further    repaired   as    in    Fig.    186. 


should  be  a  curved  one,  is  entered  close  to  the  margin  of  the  cut. 
carried  to  the  depth  of  the  wound,  and  brought  out  at  a  correspond- 
ing point  on  the  opposite  side.  A  forceps  is  noAV  fixed  to  its 
uncut  ends  and  the  suture  draAvn  to   one  side.     Two   or  three 


338 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


stitches  in  the  mucous  surface  and  two  or  three  in  the  skin  are  suf- 
ficient to  reunite  tlie  severed  parts.  Brought  together  in  this  way 
the  relations  that  obtained  when  the  section  was  made  are  approxi- 
mately restored.  It  is  Avise  to  have  the  first  stitch  one  of  silkAvorm; 
the  others  may  be  of  catgut. 

Wounds  About  the  Clitoris. — When  lacerations  occur  in  the 


Fig.   188. — Episiotomy.      The    first   suture   in   place. 


neighborhood  of  the  clitoris  the  hemorrhage  is  usually  severe. 
While  one  is  making  ready  to  repair  this  and  other  injuries,  the 
bleeding  may  be  controlled  by  a  pad  of  sterile  gauze  pressed  firmly 
against  the  symphysis.  The  precaution  should  be  taken  when 
repairing  injuries  in  this  region  not  to  include  the  urethra  in  any 
of  the  sutures  or  ligatures.     To  make  sure  that  no  such  accident 


INJURIES   OF    THE    VULVA    AND    PERINEUM  339 

occurs,  a  catheter  should  be  passed  into  the  canal  as  a  preliminary 
precaution. 

Atypical  Lacerations  of  the  Introitus. — Small  and  superficial 
wounds  of  the  mucous  membrane  require  treatment  only  in  the 
event  of  their  bleeding  too  freely.  The  larger  and  deeper  tears  are 
ahvays  to  be  sutured ;  torn  varicosities  may  require  ligating. 

PROGNOSIS 

The  prognosis  in  all  lacerations  of  the  introitus,  so  far  as  life 
is  concerned,  is  good.  Fatalities  are  rare.  Death  from  hemorrhage 
is  hardly  possible  unless  the  patient  is  without  competent  help 
when  the  laceration  takes  place.  Infection  is  generally  limited  to 
local  suppuration,  redness,  and  swelling,  without  becoming  gen- 
eral. Should  an  abscess  develop  after  a  laceration  has  been  re- 
paired, it  may  be  necessary  to  take  out  one  or  more  of  the  stitches, 
in  order  to  give  the  wound  drainage. 

The  prognosis  as  regards  anatomic  restoration  of  the  parts,  is 
not  altogether  satisfactory.  However  skillful  one  may  become  in 
the  reparation  of  such  injuries  the  structures  will  never  be  quite 
so  competent  as  they  were  before  the  injury  took  place ;  and  to 
permit  healing  to  pursue  a  spontaneous  course,  leads  to  scar  for- 
mations, some  of  which  may  become  exceedingly  distressing.  G-en- 
crally  speaking,  however,  lacerations  in  and  about  the  vulva  and 
perineum  heal  readily,  and,  when  properly  sutured,  give  rise 
to  no  functional  disturbances.  If,  for  any  reason,  they  do  not 
unite,  an  incomplete  laceration  of  the  perineum  may  again  be  su- 
tured after  ten  or  twelve  days,  the  surfaces  being  first  vivified  Avith 
a  sharp  curet  and  the  edges  freshened  with  scissors.  If  no  healing 
takes  place  in  a  complete  rupture,  it  is  best  not  to  undertake  a 
secondary  operation  before  the  expiration  of  eight  or  ten  weeks 
postpartum.  A  small  rectovaginal  or  rectoperineal  fistula  will 
oftentimes  close  if  there  is  otherwise  good  union  of  the  parts. 


CHAPTER  XXI 

THE  HEMOERHAaES  OF  CHILDBIRTH 

The  presence  of  blood  in  any  appreciable  degree,  either  before, 
during,  or  after  the  l^irth  of  the  child,  always  indicates  an  abnor- 
mality: before  labor,  it  may  come  from  a  misplaced  placenta  (pla- 
centa previa),  or  a  normalh^  placed  placenta  that  has  suffered  par- 
tial detachment  (ablatio  plaeentge)  ;  during  labor,  it  may  come  from 
a  laceration  of  the  cervix  or  from  a  rupture  of  the  uterus  as  well 
as  from  placenta  previa  and  ablatio  placentge;  after  labor,  it  may 
come  from  a  laceration  of  the  cervix  or  vagina,  or  an  inverted 
uterus,  or  it  may  come  from  the  placental  site.  Since  placenta 
previa  is  so  much  more  frequently  the  cause  of  hemorrhage  than 
any  of  those  mentioned,  it  will  be  considered  first. 

PLACENTA  PREVIA 

A  pregnancy  complicated  by  placenta  previa  (Fig.  189)  is  one 
of  the  most  serious  conditions  with  which  the  obstetrician  has  to 
deal.  Left  to  itself,  it  proves  fatal  in  four  out  of  five  cases.  But 
properly  managed,  not  more  than  one  in  ten  ends  seriously  for  the 
mother.  The  danger  comes  from  not  being  able  to  check  the  bleed- 
ing as  the  placenta  is  being  torn  from  its  connection.  Ordinarily, 
as  we  know,  this  union  is  not  broken  until  after  the  child  is  born, 
when  it  becomes  possible  for  the  uterus  to  lock  up  its  intervillous 
spaces  by  action  of  its  own  muscle  fiber.  Bleeding  generally  starts 
Ijefore  labor  begins,  but  it  does  not  often  set  in  with  any  alarming 
regularity  until  afterward.  The  problem  is  to  get  the  baby  out  of 
the  uterus  without  losing  either  the  mother  or  child,  and  to  accom- 
plish this  is  one  of  the  big  feats  of  midwifery.  Rapid  dilatation  of 
the  cervix  by  means  of  the  branched  dilator,  the  traction  balloon, 
or  even  the  hand,  is  a  risky  procedure  inasmuch  as  it  causes  trauma 
of  the  tissues  and  aggravates  the  hemorrhage.  Besides,  the  pres- 
ence of  such  lesions  so  close  to  the  placental  site  makes  them  par- 

3i0 


HEMORRHAGES    OF    CHILDBIRTH 


341 


Fig.    189. — Complete  or  central  placenta  previa.      (Redrawn  from  a  photoengraving  of  Van 
Rymsdyke's  drawing  in  the  Hunterian  Museum   of   Glasgow   University.) 


342 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


tieulaiiy  dangerous.  Delivery  by  abdominal  section  avoids  the 
lacerations,  but  the  operation  can  he  performed  in  only  a  limited 
number  of  eases.    The  patient's  family  is  not  willing,  as  a  rule,  to 


Fig.   190. — Placenta  previa;   placenta,  fetus,  and  amnion   born  intact  at  seven   months. 

subject  the  woman  to  so  formidable  a  procedure;  besides,  the  facil- 
ities for  operating  are  not  always  at  command.  Therefore,  most 
of  the  cases  of  placenta  previa  occurring  in  general  practice  will 


HEMORRHAGES    OF    CHILDBIRTH  343 

have   to  be   managed  in  other  ways   and   in  the   homes   of  the 
patients. 

TREATMENT 

Draining  the  Amnion. — To  rupture  the  amniotic  sac  serves  a 
double  purpose  in  the  management  of  placenta  previa.  With  the 
amnion  intact  the  force  of  the  uterine  contractions  is  exerted  on  the 
lower  segment  as  a  whole ;  Ijut,  if  the  sac  is  ruptured  and  the  con- 
tinuity of  the  amnion  broken,  instead  of  the  whole  lower 
segment  being  uniformly  affected,  other  portions  than  that  of  the 
placental  site  will  yield  to  the  process  of  stretching  and  will  in  this 
way  relieve  some  of  the  strain  that  otherwise  would  fall  on  the 
placental  area.  The  other  effect  is,  that  after  the  amnion  has  emp- 
tied itself  the  contractions  of  the  uterus  are  better  able  to  drive  the 
advancing  part  down  against  the  bleeding  segment  and  stop  the 
hemorrhage.  The  advantages  to  be  gained,  however,  are  not  always 
definite.  For  example,  when  a  large  section  of  the  placenta  comes 
to  lie  over  the  exit,  the  sac  having  been  opened,  hemorrhage  goes 
on  uncontrolled,  particularly  if  the  pains  become  weak  or  stop  al- 
together. The  procedure,  then,  of  draining  the  amnion, 
is  applicable  (1)  only  when  the  portion  of  placenta  that  lies  in 
front  of  the  advancing  part  is  small,  as  in  placenta  previa  mar- 
ginalis,  and  (2)  when  the  pains  are  regular  and  strong.  Nor  is 
it  always  easy  to  get  into  the  cavity  of  the  amnion,  even  if  the  pla- 
centa lies  to  one  side,  since  the  procedure  almost  always  becomes 
necessary  before  or  at  the  beginning  of  labor  when  the  cervix  is 
still  closed.  In  this  case  some  preliminary  dilating  will  need  to  be 
done,  either  with  the  fingers  or  with  some  mechanical  device. 

Making  Use  of  the  Child's  Body. — The  employment  of  the  fetus 
itself  to  control  hemorrhage,  is  an  old  and  effective  way  of  dealing 
with  placenta  previa.  Any  method  whereby  a  part  of  the  child  can 
be  held  firmly  against  the  loosened  placenta,  will  serve  to  check  its 
bleeding,  but  this  can  hardly  be  done  in  any  other  way  than  by  get- 
ting hold  of  a  foot  and  bringing  it  beyond  the  placenta  (Fig.  193). 
Even  then  it  is  not  enough,  as  a  rule,  to  let  the  delivery  go  on 
spontaneously ;  slight  but  continuous  traction  should  be  made  on 
the  child's  foot.  Thus  the  leg,  thigh,  breech,  and  body  in  turn 
serve  as  parts  of  a  dilating  wedge  that  act  as  a  tampon  to  the 


344  MAXAGEMEXT    OF    THE    SERIOUS    COMPLICATIOXS 


Fig.    191. — The    fetus,    placenta,   and   amnion    shown   in   Fig.    190   separated. 


HEMORRHAGES    OP    CHILDBIRTH 


345 


bleeding  structures.  If  a  foot  presents,  it  may  be  drawn  down  with 
comparative  ease;  in  head  and  transverse  positions,  version  be- 
comes necessary. 

In  placenta  previa  the  uterine  exit  is  more  or  less  effectually 
occluded  by  a  structure  whose  slightest  disturbance  leads  to  hemor- 
rhage; and,  while  it  is  true  that  in  almost  every  case  of  low  im- 
plantation the  bulk  of  the  placenta  lies  more  on  one  side  than  on 
the  other,  it  is  far  from  easy  to  say  on  which  side  it  lies.  The  fact 
that  when  dilatation  begins,  the  stronger  side  holds  and  the  weaker 
side  gives  way,  offers  some  clue  as  to  the  direction  the  fingers  should 
take  when  searching  for  the  amnion.     If  one  is  not  able  to  get 


Fig.    192. — Eateral,   partial,   and  complete   placenta   previa. 


around  the  placenta  in  this  way,  the  only  alternative  is  to  go  di- 
rectly through  it. 

Having  succeeded  in  introducing  two  fingers,  turning  becomes 
comparatively  easy ;  but  there  may  be  considerable  difficulty  ex- 
perienced when  it  comes  to  getting  the  foot  through  the  narrow 
cervix.  If  it  already  protrudes,  matters  are  considerably  simpli- 
fied, especially  if  labor  is  in  progress.  But  if  labor  has  not  yet 
begun,  and  bleeding  becomes  severe,  gentle  traction  should  be  made. 
As  soon  as  the  head  and  arms  have  passed  the  os  uteri,  delivery  is 
completed  after  the  Veit-Smellio  method. 

The  maternal  mortality  in  cases  managed  after  the  manner  de- 


346 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


scribed  is  about  6.5  per  cent;  the  fetal  mortality  is  above  80  per 
cent. 

The  Metreurynter. — A  cervix  that  will  admit  two  fingers  will 
permit  the  introduction  of  a  hydrostatic  bag,  which  is  passed  in  a 
collapsed  state  into  the  cavity  of  the  amnion,  distended  with  sterile 
water,  and  a  suitable  weight  attached.  Two  things  are  accom- 
plished by  it ;  bleeding  is  controlled,  and  dilatation  effected.     It 


Fig.    193. — Bipolar  version   in  placenta  previa.      (Bumm.) 


may  also  serve  another  purpose,  that  of  stimulating  uterine  con- 
tractions. So  long  as  the  metreurynter  fits  closely  and  firmly 
against  the  placenta,  there  can  be  but  little  hemorrhage,  but  when 
the  cervical  canal  dilates  to  the  size  of  the  instrument,  there  will 
be  renewed  bleeding  following  its  withdrawal  unless  the  advancing 
part  of  the  child  descends  and  takes  its  place.  This  is  hardly  pos- 
sible if  the  bag  is  a  small  one.  In  such  case  a  small  metreurynter 
should  be  followed  quickly  by  one  of  larger  size.  When  the  canal  has 


HEMORRHAGES    OP    CHILDBIRTH  347 

become  sufficiently  dilated  to  allow  the  passage  of  the  entire  hand, 
delivery  may  be  effected  by  version  and  extraction.  Dealt  with  in 
this  way,  a  child's  chances  are  better  than  with  combined  version. 
Its  disadvantages  are,  that  the  technic  is  more  complicated,  requir- 
ing greater  care  in  preparation  and  more  skill  in  the  manipulation 
of  instruments.  When  employed  in  placenta  previa  centralis,  the 
metreurynter  in  a  collapsed  state  and  held  with  forceps  is  forced 
throiigh  the  placenta. 

G-eneral  Remarks  on  Placenta  Previa 

Disinfection  of  the  operator  and  patient  is  of  fundamental  im- 
portance. 

All  examinations  and  manipulations  should  be  conducted  with 
the  patient  on  her  back. 

"When  there  has  been  much  loss  of  blood,  narcosis  becomes  in- 
creasingly dangerous.  If  employed  at  all,  ether  should  have  the 
preference  over  chloroform. 

If  the  patient  is  exsanguinated,  and  for  the  moment  stops  bleed- 
ing, the  acute  anemia  should  receive  attention  before  proceeding 
to  operate.  But  should  the  patient  be  bleeding  when  the  physician 
arrives,  his  first  object  should  be  to  check  the  hemorrhage. 

One  of  the  early  signs  of  placenta  previa  is  manifested  by  a  brisk 
discharge  of  blood  upon  rising  in  the  morning.  If  the  bleeding 
continues,  and  labor  has  begun,  the  physician  will  do  well  to  deal 
with  it  after  one  or  the  other  of  the  methods  described.  If,  how- 
ever, bleeding  stops  upon  the  patient's  going  to  bed,  one  may  ven- 
ture to  temporize. 

Instead  of  a  single  severe  hemorrhage,  there  may  be  a  moderate 
loss  of  blood  continuing  over  a  long  period  of  time,  in  which  case  it 
is  permissible  to  await  developments,  the  patient  meanwhile  being- 
kept  under  close  observation.  The  vaginal  tampon  should  not  be 
employed,  for,  in  order  to  be  effective,  it  must  be  continuous;  and 
its  continuous  use  would  be  injurious  to  the  vaginal  mucous  mem- 
brane and  would  multiply  the  dangers  of  infection. 

The  period  immediately  following  delivery  may  be  accompanied 
by  hemorrhage,  no  matter  how  favorably  the  third  stage  of  labor 
terminates.    Besides,  the  adventitious  location  of  the  placenta  inter- 


348  MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 

feres  with  the  mechanism  of  its  detachment.  One  should  bear  this 
in  mind,  and  not  delay  too  long  the  completion  of  its  delivery;' 
otherwise,  the  loss  of  blood  accompanying  it,  may,  in  the  presence 
of  an  already  severe  anemia,  prove  fatal. 

Another  source  of  hemorrhage  in  placenta  previa  is  the  cervix 
itself.  A^ascularized  as  it  is  by  placental  infiltration,  the  tissues 
become  friable  and  easily  torn;  therefore,  much  care  in  the  ex- 
aminations and  treatment  must  be  exercised. 

Premature  Separation  of  the  Normally  Situated  Placenta 

Symptoms  and  Diagnosis. — It  occasionally  happens  that  the 
normally  placed  placenta  becomes  prematurely  separated  from  its 
uterine  connection  (Fig.  194).  This  severe  complication  is  equally 
dangerous  to  mother  and  child.  Its  etiology  lies  chiefly  in  the  kid- 
ney, whose  inflammatory  condition  may  be  the  occasion  of  decidual 
degeneration.  Violence  is  another  cause  of  separation,  as,  for  ex- 
ample, a  fall  on  the  body  or  a  blow  over  the  abdomen.  The  re- 
sulting hemorrhage  is  essentially  an  internal  one,  since  it  may  be 
confined  betwen  the  amnion  and  the  uterine  wall.  Blood  may 
force  its  way  externally,  but  the  amount  that  shows  is  only  a  small 
part  of  what  is  lost ;  so  that  the  symptoms  of  hemorrhage  are  not 
in  keeping  with  the  amount  of  blood  to  be  seen :  the  anemia  is  in- 
creased, the  patient  is  in  shock,  and  the  uterus  shows  a  sudden  in- 
crease in  size,  tension,  and  sensitiveness.  If  the  placenta  is  only- 
partially  separated,  the  consequences  are  not  necessarily  fatal  to 
the  child;  complete  detachment  of  course  would  be.  The  situation 
can  be  so  serious  as  to  look  like  rupture  of  the  uterus,  and  is:  some- 
times mistaken  for  it.  There  is  this  difference,  however :  in  one  the 
uterus  enlarges  rapidly  and  there  is  no  recession  of  the  advancing 
part ;  in  the  other  the  uterus  becomes  rapidly  smaller,  and  there  is 
recession  of  the  advancing  part. 

Treatment. — Inasmuch  as  it  is  not  possible  to  reach  the  bleeding 
part,  the  only  thing  to  do  is  to  deliver,  after  which  the  uterus  it- 
self is  capable  of  arresting  the  hemorrhage. 

If  the  cervix  is  sufficiently  dilated,  delivery  may  be  effected  with 
forceps,  or  by  version  and  extraction ;  or,  if  the  child  is  dead,  it 
may  be  delivered  by  perforation  and  cranioclasis.  Unfortunately, 
however,  the  complication  frequently  occurs  at  the  very  beginning 


tlEMORRHAGES    OP    CHILDBIRfPT 


349 


of  labor,  or  even  before,  so  that  one  will  not  be  able  to  make  use  of 
the  simpler  operations.     Under  such  circumstances  the  treatment 


Fig.    194. — Premature    separation    of    the    normally   placed    placenta.      (After    Winter.) 

must  depend  on  the  severity  of  the  clinical  picture.    If  the  anemia 
is  slight,  the  cervix  eifaced,  and  only  the  external  os  is  to  be  dilated, 


350  MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 

all  that  may  be  necessary,  in  order  to  control  the  bleeding,  will  be 
to  rupture  the  amniotic  sac.  By  doing  this  the  size  of  the  uterus 
is  reduced  and  sufficient  pressure  obtained  to  keep  the  hemorrhage 
within  safe  limitations.  One  may  even  take  into  consideration  ar- 
tificial dilatation;  or,  a  foot  may  be  brought  through  the  cervix, 
and  the  child's  body  itself  employed  as  a  dilator.  But  for  the  most 
part,  the  condition  is  too  severe  to  w^arrant  much  temporizing.  In 
the  hospital  and  under  competent  hands  rapid  delivery  can  be  ac- 
complished by  vaginal  cesarean  section,  or  by  divulsion  of  the  cer- 
vix with  one  of  the  metal  dilators,  aided  perhaps,  by  multiple  in- 
cisions after  the  method  of  Diihrssen.  And  since  the  hemorrhage 
is  almost  always  fatal  to  the  child,  its  delivery  can  be  expedited  by 
perforation  and  cranioclasis.  Outside  the  hospital  one  would 
hardly  dare  undertake  to  do  more  than  turn  and  extract. 

The  placenta  usually  follows  at  once,  accompanied  by  an  accumu- 
lation of  blood  and  coagulum.  Indeed,  the  uterus  may  empty  it- 
self so  rapidly  that  its  atony,  added  to  the  existing  anemia,  will  be 
too  great  for  the  patient  to  \\'ithstand.  To  meet  such  emergency, 
one  should  be  prepared  to  pack  immediately. 

An  illustrative  case  of  premature  separation  of  the  placenta  is 
cited : 

Soon  after  lifting  a  heavy  load,  a  multiparous  woman  near  the  end  of 
pregnancy,  experienced  great  difficulty  in  breathing ;  fetal  movement  ceased ; 
the  abdomen  became  distended.  Imagining  the  bowels  and  bladder  to  be  re- 
sponsible for  the  symptoms,  she  sought  to  force  an  opening,  and  fainted. 
Slight  bleeding  from  the  vagina  appeared. 

When  brought  to  the  hospital,  the  following  conditions  were  found:  severe 
anemia ;  pulse  140  and  thready ;  abdomen  much  distended,  so  much  so  that 
fetal  parts  could  not  be  palpated,  nor  the  child's  heart  heard.  There  was 
some  bleeding  from  the  birth  canal.  Cervix  shortened,  admitting  two  fingers. 
Amniotic  sac  still  intact ;  hydrostatic  tension  slight.  ISTo  placental  tissue  could 
be  felt ;  head  engaged ;  urine  contained  albumin. 

Diagnosis :  premature  detachment  of  a  normally  located  j^lacenta ;  bleeding 
in  the  uterine  cavity ;  dead  f ef us ;  severe  anemia. 

Delivery  immediately  undertaken.  The  cervix  was  dilated  with  the  Leavitt 
branched  dilator,  the  head  perforated,  and  the  child  extracted  with  the  cra- 
nioclast.  After  the  child  had  been  removed,  the  uterus  still  remained  large, 
extending  almost  to  the  border  of  the  ribs.  Upon  exerting  pressure  on  the 
fundus  there  came  away  with  the  placenta  two  liters  of  blood,  two-thirds  of 
which  was  clotted.  The  uterus  remained  somewhat  atonic,  and  was  at  once 
packed  with  iodoform  gauze.  Meanwhile  two  doses  of  ergotine  were  given 
liv'podermically.     Also,  while  these  measures  were  being  carried  out,  treatment 


HEMORRHAGES    OF    CHILDBIRTH  351 

for  the  anemia  was  begun.  The  placenta  showed  that  it  had  been  strongly- 
compressed,  and  its  surface  was  covered  with  coagulated  blood.  The  tear  in 
the  amnion  was  almost  in  the  center. 

If  the  periphery  of  the  placenta  remains  adherent,  so  that  hemor- 
rhage becomes  confined  to  its  inner  surface,  a  bulging  tumor  at  this 
point  may  be  seen  externally.  Occasionally  the  hemorrhage  will 
rupture  through  the  border  of  the  placenta  and  show  at  the  vulva. 
The  report  of  such  a  case  follows  : 

Soon  after  labor  began  blood  appeared  externally.  At  the  hospital,  where 
the  patient  was  immediately  taken,  the  following  conditions  were  observed: 
marked  anemia;  uterus  deflected  to  the  left;  large  boggy  swelling  at  the  side 
of  the  fundus.  The  presentation  was  left  parietal.  Heart  sounds  not  heard. 
Continuous  discharge  of  blood  from  the  genitals.  Within  the  vagina  lay  a 
loop  of  the  pulseless  umbilical  cord  and  an  arm  of  the  child.  Nowhere  could 
the  margin  of  the  placenta  be  reached. 

Diagnosis:  first  position  of  the  vertex;  prolapse,  of  the  arm  and  cord;  child 
dead;  premature  detachment  of  the  normally  placed  placenta. 

Delivery  was  completed  by  perforation  and  cranioclasis.  Immediately  fol- 
lowing the  birth  of  the  child  al^out  25  ounces  of  fluid  blood  came  away  with 
the  placenta,  the  placenta  itself  showing  a  I'upture  through  a  sinus  near  its 
border.    No  untoward  morbidity  followed. 

In  rare  cases  a  completely  detached  placenta  may  fall  in  advance 
of  the  child,  and  be  born  first  (prolapse  of  the  placenta).  The  fol- 
lowing is  a  report  of  such  a  case : 

The  stage  of  dilatation  ran  on  without  any  unusual  manifestations;  espe- 
cially was  there  no  discljarge  of  blood  until  the  sac  ruptured,  when  half  a 
pint  of  blood  ran  off.  The  obstetric  findings  were  as  follows:  uterus  at  the 
border  of  the  ribs;  head  in  the  fundus;  absence  of  fetal  heart  sounds.  From 
the  vulva  projected  the  right  foot,  near  which  placental  tissue  could  be  seen. 
After  an  expulsive  pain  the  entire  i)lacenta,  which  lay  in  front  of  the  child, 
was  born,  the  membranes  still  adherent  to  the  uterus.  Fetus  hastily  extracted, 
but  not  alive. 

A  much  more  favorable  course  may  be  expected  when  during 
labor  a  rapidly  diminished  volume  is  the  occasion  of  a  partial  de- 
tachment of  the  placenta,  as,  for  example,  in  hydramnion  after 
rupture  of  the  sac,  or  in  twins  after  the  birth  of  the  first  child. 
Usually,  the  hemorrhage  is  not  great;  it  shows  externally,  and  is 
chiefiy  of  danger  to  the  child.  Deliverj^,  when  possible,  should  be 
undertaken  immediately. 

Premature  detachment  of  the  placenta  may  sometimes  be  charged 


352  MANAGEMENT    OE    THE    SERIOUS    COMPLICATIONS 

to  the  cord,  which,  primarily,  may  be  abnormall}'  short  or  be  made 
so  by  twining  about  the  child's  body.  The  delivery  of  the  placenta 
under  these  conditions  is  easily  effected.  The  intact  membranes 
when  forced  through  the  vulva  also  can  loosen  the  placenta.  Re- 
lief here  lies  in  immediate  rupture  of  the  sac. 

The  outlook  in  all  the  hemorrhages  of  childbirth  is  not  nearly  so 
serious  for  the  mother  as  for  the  child,  the  mortality  for  the  latter 
being  more  than  fifty  per  cent. 


CHAPTER  XXII 

MULTIPLE  BIRTH 

Multiple  birth,  iisually  in  the  form  of  twins,  occasionally  in  trij)- 
lets,  rarely  in  quadruplets,  while  not  necessarily  complicated,  al- 
ways requires  increased  attention  on  the  part  of  the  physician 
to  see  that  breech  positions,  cross-births,  and  the  various  deflec- 
tions of  the  head  do  not  interfere  with  labor.  Owing  to  their 
relatively  small  size,  the  fetuses  themselves  do  not  add  to  the 
mechanical  difficulties:  they  rather  decrease  them.  Nor  is  pre- 
mature induction  of  labor,  pubiotomy,  or  cesarean  section,  because 
of  pelvic  contraction,  often  necessary.  The  unfavorable  brow  po- 
sition, also,  will  generally  correct  itself  spontaneously;  and  even 
prolapse  of  the  cord  will  terminate  favorably.  There  are,  how- 
ever, certain  conditions  in  every  jjliase  of  a  multiple  birth  that 
call  for  special  treatment. 

TWINS 

The  First  Twin. — Labor  in  the  case  of  twins  is  ushered  in  with 
distinctly  impaired  forces.  The  abnormal  stretching  of  the  uterus 
often  leads  to  a  state  of  innervation  that  makes  artificial  aid  nec- 
essary. In  this  respect  the  condition  is  not  unlike  that  of  hydram- 
nion.  "When  the  amount  of  amniotic  fluid  is  greatly  increased,  as 
it  oftentimes  is,  it  may  be  necessary  to  rupture  the  sac  before  the 
uterus  can  effectually  contract.  It  should  be  borne  in  mind,  though, 
that  decomposition  of  the  retained  fluid  with  fever  of  the  mother 
and  asphyxiation  of  the  child  may  result  if  rupture  is  not  soon  fol- 
lowed by  delivery.  For  this  reason  it  may  be  advisable  not  to  wait 
for  its  spontaneous  birth,  but  to  deliver  the  child  instrumentally 
or  otherwise  at  once.  In  about  twenty-eight  per  cent  of  twin  preg- 
nancies this  will  be  found  expedient.  Still  one  must  not  be  too  hasty, 
for  even  here  spontaneous  birth  offers  the  best  surety  against  com- 
plications. 

3.53 


354  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

The  Interval. — Following  tlie  birtli  of  the  first  twin,  and  before 
the  second  is  delivered,  several  things  may  happen  that  require  con- 
sideration. First,  the  marked  decrease  in  size  of  the  uterus  some- 
times causes  a  partial  separation  of  the  placenta,  which  may  result 
in  asphyxiation  of  the  second  twin.  It  is  essential,  therefore,  that 
the  fetal  heart  be  listened  to  at  frequent  intervals  during  this  in- 
terim, and  preparations  made  to  deliver  ciuickly  should  the  heart 
appear  to  be  failing.  Second,  the  possibility  of  the  remaining  twin 
bleeding  to  death  through  the  placenta  and  cord  of  the  first  should 
not  be  forgotten.  To  prevent  such  an  unfortunate  occurrence  the 
funis  of  the  one  born  first  should  be  securely  clamped  or  tied  while 
awaiting  the  birth  of  the  other.  Particularly  is  such  precaution 
necessary  in  the  case  of  unioval  twins. 

The  period  of  inactivity  following  the  birth  of  the  first  twin  may 
be  utilized  in  making  an  exact  diagnosis  of  the  position  of  the  child 
still  to  be  born.  This  can  be  done  generally  by  external  palpation 
alone,  but  when  in  doubt  one  ought  not  to  hesitate  to  make  an  in- 
ternal examination,  as  well.  Even  then  mistakes  not  infrequently 
happen,  as  may  be  seen  in  the  following  instances: 

A  case  was  diagnosed  as  one  of  twins.  After  turning  and  extracting  the 
first  child,  which  lay  in  a  cross  position,  the  attending  physician  went  directly 
with  the  hand  into  the  uterus  to  deliver  the  other  twin  without  making  an 
external  examination.  The  cavity  was  found  to  be  empty;  and  what  he  took 
to  be  a  second  fetus  proved  to  be  a  bicornate  utems. 

A  young  doctor  brought  a.  woman  said  to  be  pregnant  with  twins  to  the 
hospital.  The  first  child,  which  presented  by  the  breech,  was  delivered.  He  then 
made  a  surface  examination,  and,  being  convinced  that  the  remaining  child 
occupied  a  transverse  positioii,  sought  to  convert  it  by  external  manipulations 
into  a  head  presentation.  His  efforts  failing,  he  called  in  consultation  a  more 
experienced  obstetrician,  who  found,  in  place  of  a  head,  a  large  submucous 
myoma. 

A  careful  examination,  one  which  combined  both  internal  and 
external  palpation,  would  greatly  have  aided  the  diagnosis  in  either 
of  these  cases. 

The  Second  Twin. — As  a  -rule  the  second  child  follows  the  first 
within  a  period  of  from  thirty  to  sixty  minutes;  but  the  interval 
may,  if  allowed  to  pursue  its  own  course,  be  prolonged  for  several 
hours  or  days  or  even  weeks.  Such  a  course  would  not  be  desir- 
able. In  the  first  place  the  delay  demands  the  presence  of  the  ac- 
coucheur or  a  skilled  assistant  during  the  entire  time ;  and,  in  the 


MULTIPLE    BIRTH  355 

second  place,  it  invites  contamination,  since  the  passage  of  the  first 
child  is  sure  to  leave  in  its  wake  numerous  lesions  that  are  partic- 
ularly susceptible  to  infection.  A  too  rapid  emptying  of  the  uterus, 
on  the  other  hand,  is  also  dangerous  inasmuch  as  serious  hemor- 
rhage sometimes  accompanies  the  atony  which  follows  when  the 
overdistended  uterus  is  speedily  evacuated.  A  safe  rule  to  follow 
in  the  absence  of  indications  demanding  interference  earlier,  is 
to  rupture  the  sac  at  the  end  of  two  hours  and  give  a  dose  of 
pituitary  extract.  Those  of  much  experience  may  ventui^e  to 
cut  the  time  of  waiting  down  to  an  hour  or  even  thirty  minutes. 
Instead  of  the  pituitary  extract,  ergot  may  be  given  with  much 
the  same  effect. 

It  is  quite  common  for  the  second  child  to  assume  a  transverse 
position,  which  easily  may  be  converted  externally  into  a  longitudi- 
nal one  if  done  before  the  sac  ruptures.  If,  however,  the  sac  has 
already  ruptured,  and  the  amniotic  fluid  has  drained  off,  the  tend- 
ency is  for  the  fetus  to  become  immobilized. 

Interference  of  some  sort  in  the  birth  of  the  second  tw^in  becomes 
necessary  in  about  fifty  per  cent  of  the  eases,  the  most  frequent 
operation  being  that  of  version  and  extraction. 

The  Placental  Period. — The  birth  of  twdns  is  frequently  followed 
by  a  state  of  atony.  This  is  due  in  part  to  the  lack  of  muscle  tone, 
noticeable  throughout  labor,  and  in  part  to  the  sudden  relief  of 
pressure  in  the  overstretched  uterus.  The  increased  size  and  ab- 
normal form  of  the  placenta  has  doubtless  some  influence,  too.  In 
a  relatively  large  number  of  cases  manual  separation  of  the  placenta 
will  be  necessary,  so  that  one  should  always  be  prepared  with  ergot, 
apparatus  for  giving  infusions,  disinfecting  solutions,  sterile  gloves, 
and  restoratives.  Even  after  the  placenta  has  been  expelled,  there 
may  be  need  for  these  things  because  of  the  atony  that  sometimes 
follows.  The  uterus  should  be  watched  for  an  hour  or  more 
to  see  that  it  remains  firmly  contracted. 

RARE  COMPLICATIONS 

Peculiar  complications  arise  when  both  amniotic  sacs  rupture 
before  the  birth  of  the  first  child.  The  most  remarkable  twisting 
and  interlocking  of  the  fetuses  can  then  occur.  Far  example,  the 
prolapse  of  an  extremity  or  cord  of  one  child  may  so  fix  itself  about 


356 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


the  other  as  to  make  delivery  exceedinglj^  difficult,  or,  possibly, 
cause  fetal  death.  Under  these  circumstances  effort  should  be 
made  to  save  only  the  living  child.  If  both  lie  in  the  head  position, 
the  head  of  the  second  fetus  may  sink  into  the  pelvis  before  that  of 
the  first  is  fully  born.  Deliveiy  by  forceps  of  the  most  depend- 
ent head  would  then  be  necessary.     Should  the  head  of  the  second 


Fig.    195. — Interlocking  heads  in  the  birth  of  twins.     In  the  birth  of  the  first  twin,  which 
is  coming  breech    first,   the  head   has   become  arrested   by   the   head   of  the   other  twin. 

child  come  down  into  the  pelvis  after  the  head  of  the  first  has  been 
born,  it  may  be  necessary  to  extract  the  second  one  before  the  de- 
livery of  the  first  can  be  completed.  Even  perforation  and  cranio- 
clasis  may  have  to  be  resorted  to. 

In  dealing  with  the  breech  position  of  the  first  child,  the  head  of 
the  second  descending  before  the  first  is  born,  the  one  presenting 


MULTIPLE    BIRTH  357 

by  the  breech  must  give  way  to  the  other ;  otherwise  there  would  oc- 
cur a  serious  interlockiug  as  the  head  of  the  first  child  attempted 
to  pass  the  head  of  the  second  (Fig.  195).  Again,  if  the  head  of 
the  second  child  comes  down  into  the  pelvis  when  the  first  is  nearly 
born  it  may  be  possible  to  push  the  second  head  back  far  enough  to 
allow  the  complete  birth  of  the  first  child.  If  both  children  lie  in- 
terlocked in  the  breech  position,  the  lower  one  should  be  extracted 
first.  In  the  rare  situation  of  one  child  lying  so  that  its  head  be- 
comes locked  in  the  neck  of  the  other,  as  may  happen  when  one  fe- 
tus lies  in  a  cross  position  and  the  other  presents  by  the  breech,  a 
dismembering  operation  generally  becomes  necessary,  though  some 
attempt  to  push  the  one  lying  transversely  up  out  of  the  way  should 
first  be  made. 

Further  Observations  Concerning  Twins 

In  the  birth  of  twins  the  frequency  of  the  breech  presentation, 
as  compared  Avith  head  presentations,  is  as  one  to  two.  This  is  true 
of  both  twins.  The  proportion  of  transverse  positions,  comparing 
the  first  twin  with  the  second,  is  as  one  to  four. 

Another  thing  to  be  noticed  in  the  birth  of  twins  is,  that  as- 
sistance more  frequently  becomes  necessary  in  the  delivery  of  the 
second  child  than  of  the  first.  And  while  forceps  is  employed 
three  or  four  times  oftener  in  delivering  the  first  tAvin  than 
version,  version  is  performed  ten  times  oftener  in  delivering  the 
second  twin  than  it  is  delivering  the  first. 

The  mortality  in  twin  pregnancy  is  practically  nothing  for  the 
mother;  but  for  the  children  it  reaches  eighteen  per  cent.  So  high 
a  rate  for  them  is  due,  not  so  much  to  the  difficulties  of  birth  itself, 
as  to  the  disturbed  intrauterine  relation,  which  may  cause  one  or 
both  to  perish  before  they  are  born. 


CHAPTER  XXIII 

THE  TRANSVERSE  POSITION 

The  transverse  position  almost  always  calls  for  help.  In  rare 
instances  and  under  peculiar  circumstances  the  child  may  be  born 
without  assistance ;  but  this  is  only  possible  when  the  position  of  the 
child  changes  to  a  longitudinal  one  spontaneously,  or  the  child  is 
forced  through  the  birth  canal  in  a  greatly  distorted  form.  The 
evolution  of  a  cross-birth  into  a  longitudinal  one  can  come 
about  only  Avhen  the  head  or  the  breech  at  the  beginning  of 
labor  lies  near  the  pelvic  inlet.  Its  conversion  into  one  or  the 
other  of  these  positions  is  favored  still  further  by  the 
posture  of  the  mother.  Termination  of  labor  with  the  child  still 
lying  transversely  but  in  a  distorted  attitude  can  occur  through 
the  advancing  shoulder  being  driven  under  the  symphysis,  the 
body  of  the  child  following  in  its  long  axis, — tirst  the  breast,  then 
the  abdomen  and  buttocks,  and  finally  the  lower  extremities  (Figs. 
196  and  197).  Usually  the  last  part  to  be  born  is  the  head, 
but  instead  of  it  coming  last,  the  child  may  sometimes  be  so  strongly 
folded  upon  itself  (Fig.  198)  that  the  head  lies  in  advance  of  the 
buttocks,  and,  in  this  attitude,  the  shoulder  passes  under  the 
symphysis  first,  followed  by  the  head  and  then  the  buttocks.  It 
would,  however,  be  impossible  for  a  child  to  be  born  in  either  of 
these  attitudes  unless  the  explusive  forces  were  strong,  the  pelvis 
wide,  and  the  fetus  compressible ;  and  it  could  hardly  occur  at  all 
except  in  very  small  children  (twins),  premature  births,  and  mac- 
erated fetuses. 

TREATMENT 

The  most  favorable  turn  for  a  cross-birth  to  take  is  for  the  head 
to  fall  into  presentation.  If  this  does  not  occur  spontaneously,  ex- 
ternal version  may  be  made.  But  there  are  certain  conditions  which 
make  it  inadvisable  always  to  do  this.  For  example,  if  the  breech 
occupies  a  position  nearer  than  the  head  to  the  pelvic  inlet,  it 


THE    TRANSVERSE   POSITION 


359 


would  be  better  to  favor  the  evolution  of  that  pole  instead.  Or,  if 
some  of  the  essential  preliminary  conditions  are  wanting  to  make 
external  version  by  the  head  fairly  easy  of  accomplishment,  version 
by  the  foot  would  be  indicated,  and  extraction  possible. 

There  is,  then,  in  cross-births  an  opportune  moment  when  version 
should  be  undertaken,  or  not  undei'taken  at  all.  Neglected  beyond 
this  point,  the  forces  of  labor  soon  immobilize  the  child  so  com- 
pletely that  nothing  remains  to  be  done  but  to  remove  it  by  em- 
bryotomy. The  shoulder  is  driven  into  the  excavation,  the  lower 
segment  of  the  uterus  retracts,  the  ring  of  Bandl,  with  its  vise- 


Fig.   196. — Spontane'Ous   evolution.      (Bumm.) 

like  constriction,  closes  in  upon  the  fetus,  and  the  child  finally  be- 
comes asphyxiated.  If,  perchance,  it  is  still  living,  an  effort  should 
be  made  under  deep  anesthesia  to  release  it.  The  attempt,  how- 
ever, must  be  carefully  conducted,  and  not  persisted  in  for  more 
than  a  few  minutes.  If  the  child  is  dead,  even  a  trial  version  is 
not  advisable,  but  embryotomy  should  be  performed  instead. 

So  long  as  the  amnion  remains  unruptured,  neither  the  mother 
nor  the  fetus  is  in  any  immediate  danger;  but,  if  the  sac  has  rup- 
tured and  the  amniotic  fluid  drained  awa}^,  the  uterus  soon  con- 
tracts about  the  fetus  so  tightly  that  manipulations  become  ex- 
ceedingly difficult,  even  dangerous^  although  the  danger  is  not  so 


360  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


Fig.   197. — Spontaneous    evolution.      (Bumm.) 


THE    TRANSVERSE    POSITION 


361 


Fig.   198. — Partus  conduplicato   corpore.      (Zangemeister.) 


Fig.    199. — Spontaneous   evolution    in   a   cross-birth.      Reported    by    Dr.    H.    A.    Stephenson. 
The   impaction   of  the  shoulder. 


- 

/ 
/ 

/ 

i 

1 

Fig.   200. — The   arm   pi-olapsed. 


Fig.   201. — The  occiput  has  rotated  ahiiost  directly  anterior  and   lies  just  above  the  pubis; 
the  neck  much  elongated;  left  shoulder  emerging  from  beneath  the  pubic  arch- 


THE    TRANSVERSE    POSITION 


363 


great  as  to  prevent  one  from  making  some  effort  to  save  the  child's 
life. 

Finding  the  cervix  still  short  of  complete  dilatation,  the  sac  in- 
tact or  but  recently  ruptured,  a  hydrostatic  bag  will  be  of  service. 
Besides  aiding  dilatation,  it  acts  as  an  efficient  plug,  preventing 
the  sac  from  sagging  and  the  shoulder  from  sinking  into  the 
pelvis.  A  prolapsed  arm  or  loop  of  cord  should,  of  course, 
first  be  replaced  before  attempting  to  introduce  the  metre- 
urvnter. 


Fig.  202. — The  child  has  undergone  a  movement  of  rotalion,  the  prolapsed  arm  re- 
turned to  the  side  of  the  mother  toward  which  it  was  originally  directed,  thus  bringing 
the   occiput   under   the   pubic   arch  in   the   most   favorable   position   for    easy   expulsion. 


In  considering  the  best  interests  of  the  child,  one  awaits  com- 
plete dilatation  of  the  cervix  before  undertaking  version  and  ex- 
traction ;  otherwise  the  larger  end  of  the  fetal  wedge,  which  comes 
last,  will  be  delayed  at  a  time  when  delay  is  dangerous.  If  it  can 
be  established  that  the  child  is  no  longer  alive,  version  may  be 
done  early  and  labor  allowed  to  go  on  naturally. 

The  prolapse  of  a  foot  or  an  arm  or  of  the  umbilical  cord  is  of 
common  occurrence  in  transverse  positions.     Prolapse  of  the  foot 


364  MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 

is  accounted  to  be  favorable,  since  labor  may  go  on  to  a  spontaneous 
termination ;  and,  if  it  does  not,  the  member  furnishes  a  convenient 
handle  on  which  to  make  traction.  No  effort  should  be  made  to 
replace  a  prolapsed  arm.  The  attempt  would  be  futile,  anyway, 
and  would  multiply  the  dangers  of  infection.  Later,  it  furnishes 
something  to  pull  on  when  trying  to  bring  the  fetus  within  range 
of  the  decapitation  hook,  should  its  use  be  found  necessary.  It  is 
also  true  of  the  cord,  when  it  falls  down,  that  no  effort  to  return  it 
should  be  made;  the  shoulder  so  completely  fills  the  encircling  gir- 
dle of  the  canal  that  it  could  not  be  done. 


CHAPTER  XXIV 
DEFLECTIONS  OF  THE  HEAD 

THE  OCCIPITOPOSTERIOR  POSITION 

The  occipitoposterior  position  is  one  in  which  the  head  of  the 
child  lies  with  the  smaller  or  posterior  fontanel  in  the  hollow  of  the 
sacrum,  the  large  or  anterior  fontanel  lying  under  the  symphysis 
pubis.  The  glabella  meets  with  the  arch  in  front,  beneath  which  it 
slides ;  the  occiput  passes  along  the  floor  of  the  pelvis,  and  escapes 
over  the  perineum.  A  child  in  this  position  is  often  born  spon- 
taneously, but  the  process  is  usually  a  long  and  tedious  one.  The 
functionating  diameter  of  the  head  is  increased  over  what  it  is  in  the 
more  favorable  anterior  position ;  and,  besides,  the  head  can  not 
adapt  itself  so  readily  to  the  birth  canal.  It,  therefore,  becomes 
desirable  to  convert  it  into  a  more  favorable  position.  If  this  can 
not  be  done,  the  case  must  l)e  managed  in  some  other  way. 

There  are  two  measures  which  favor  the  rotation  of  the  head 
from  a  posterior  to  an  anterior  position  of  the  vertex ;  namely, 
keeping  the  patient  on  the  side  toward  which  the  small  fontanel 
is  turned,  and  the  maintenance  of  flexion  of  the  child 's  head.  Thus 
will  the  occiput,  the  part  first  to  meet  with  resistance,  tend  to  ro- 
tate anteriorly.  Failing  to  take  this  more  favorable  turn,  and  per- 
sisting in  the  posterior  position,  it  is  recommended  as  a  prophylac- 
tic measure  that  a  vaginoperineal  section  be  made.  The  technic  of 
forceps  delivery  in  this  position  is  described  on  page  190.  If  the 
fetus  is  dead,  delivery  with  the  cranioclast  should  be  undertaken 
Avithout  further  delay.  The  operation  saves  the  mother's  tissues 
as  well  as  her  strength,  and  is  always  justifiable  under  such  cir- 
cumstances; but  there  should  be  no  mistaking  a  living  for  a  dead 
child. 

Treated  expectantly,  more  than  eighty  per  cent  of  the  occipito- 
posterior positions  will  terminate  spontaneously ;  the  remaining 
twenty  per  cent  require  the  aid  of  forceps.    As  for  life,  the  mother 

365 


366  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

is  never  in  any  particular  danger.  The  risks  for  the  child,  how- 
ever, are  considerably  increased;  and  whether  spontaneously  born 
or  delivered  with  forceps,  the  fetal  mortality  is  about  the  same, 
namely,  fifteen  per  cent. 

PRESENTATIONS  BY  THE  FACE 

A  face  presentation  will  in  most  instances  terminate  sponta- 
neously. The  tendency  is  for  the  bulky  occiput  to  find  its  way  into 
the  hollow  of  the  sacrum,  the  chin  turning  to  the  front.  In  this 
position  flexion  begins  as  soon  as  the  chin  passes  under  the  symphy- 
sis, folloAving  which  the  brow,  vertex,  and  occiput  rotate  in  suc- 
cession over  the  perineum.  Owdng  to  the  irregular  contour  of  the 
face,  the  membranes  are  subjected  to  an  unecpial  pressure  that 
favors  their  early  rupture.  For  the  same  reason  the  cord  or  a 
fetal  member  is  permitted  to  slip  by. 

An  exceedingly  unfortunate  evolution  in  face  presentations  is 
for  the  chin  to  rotate  posteriorly  into  the  hollow  of  the  sacrum,  the 
forehead  coming  against  the  symphysis  in  front.  Birth  in  this  po- 
sition is  practically  impossible.  If  the  head  is  freely  movable  above 
the  pelvic  inlet,  one  may  attempt  to  change  the  face  presentation 
position  into  an  anterior  position  of  the  occiput  by  flexing  the  chin 
forward  (the  Thorn  manipulation.  Fig.  43),  or  perform  version 
and  extraction.  If  neither  of  these  procedures  is  judged  to  be  safe, 
because  of  the  danger  of  rupturing  the  uterus,  the  operator  may, 
even  in  a  living  child,  be  forced  to  perforate  through  the  orbit  and 
deliver  with  the  cranioclast.  Such  a  procedure,  however,  is  to  be 
countenanced  only  when  the  facilities  for  performing  cesarean 
section  are  inadequate. 

If  the  head  remains  above  the  inlet  with  the  cervix  fully  dilated, 
an  arm  or  the  cord  fallen  down,  version  and  extraction  are  indi- 
cated. If  the  cervix  is  not  fully  dilated  and  the  prolapsed  cord  is 
pulsating,  it  may  be  worth  while  trying  to  reduce  the  dislocation 
pending  further  developments. 

If  the  head  has  descended,  but  remains  fixed,  we  have  a  valuable 
ally  in  the  forceps.  AVith  the  face  lying  anteroposteriorly,  the 
blades  are  applied  to  the  sides  of  the  head,  their  coaptation  in  this 
position  being  exceptionally  favorable.     If  the  face  presents  ob- 


Dee'lections  of  the  head  367 

liquely,  the  application  of  forceps  should  be  made  in  the  oblique 
diameter  of  the  pelvis.  The  adjustment  of  the  instrument  in  this 
position  is,  however,  more  difficult  and  its  hold  less  secure. 

PRESENTATION  BY  THE  BROW 

As  in  face  presentations,  a  brow  presentation  will  occasionally 
terminate  spontaneously;  but  usually  it  demands  obstetric  inter- 
ference, especially  if  the  mother's  pelvis  and  the  child's  head  are  of 
normal  proportions. 

If  the  head  has  become  arrested  in  descent  the  use  of  forceps  is 
indicated ;  if  it  still  lies  above  the  inlet,  an  attempt  should  be  made 
to  convert  the  presentation  into  another  and  more  favorable  one, 
such  as  a  vertex,  footling,  or,  perhaps,  a  face.  Since  the  most  fre- 
quent position  of  the  brow  is  one  with  the  occiput  lying  posteriorly, 
it  is  out  of  this  position  that  an  oceipitoposterior  position  of  the 
vertex  may  be  secured.  (See  Thorn's  method,  page  108.)  In  some 
instances  it  may  be  easier  and  more  desirable  to  extend  the  head 
instead  of  flexing  it,  thus  making  a  face  presentation  with  the  chin 
under  the  symphysis. 

If  the  head  already  has  become  arrested,  a  competent  surgeon 
would  probably  undertake  cesarean  section ;  one  less  experienced 
would  prefer  to  deliver  with  forceps.  Even  then  instrumental  de- 
livery should  not  be  attempted  unless  it  is  well  established  from  bi- 
manual examination  that  the  head  is  well  down  in  the  pelvis. 
Spontaneous  birth  is  only  possible  when  the  child  is  small,  the  birth 
premature,  or  the  fetus  macerated. 


CHAPTER  XXV 

PEOLAPSE  OF  THE  UMBILICAL  CORD 

In  considering  the  subject  of  cord  displacement,  a  distinction  is 
made  between  forelijing  and  prolapse,  qnite  different  causes  being 
ascribed  to  each.  The  one  is  a  primary,  the  other  a  secondary, 
condition.  Forelying,  or  presentation  of  the  cord,  as  some  prefer 
to  call  it,  is  the  result  of  either  an  abnormally  long  cord,  a 
velamentous  or  marginal  insertion,  or  a  very  low  situation  of  the 
placenta.  Every  case  of  presentation  l^ecomes  one  of  prolapse  as 
soon  as  the  membranes  rupture;  but  it  does  not  follow  that 
every  case  of  prolapse  is  first  one  of  presentation.     (Fig.  203.) 

Prolapse  is  the  result  of  a  combination  of  two  conditions,  mal- 
adaptation  and  hydrostatics;  the  presenting  part  of  the  fetus  does 
not  fit  the  bony  girdle  of  the  pelvis,  so  that,  when  the  amnion- gives 
way,  the  .dependent  funis  is  carried  outward  by  the  gush  of  escap- 
ing water. 

While  displacement  of  the  umbilical  cord  is  profoundly  serious, 
so  far  as  the  child  is  concerned,  it  is  accompanied  by  little  danger 
to  the  mother.  Aside  from  the  casualties  incident  to  rapid  de- 
livery, and  the  manipulations  of  replacement,  dilatation,  etc.,  there 
are  no  serious  consequences. 

Inasmuch  as  the  gravity  of  a  prolapse  depends  largely  on  the 
position  of  the  fetus  at  time  of  l^irth,  it  will  be  well  to  study  the 
subject  from  this  point  of  view. 

Prolapse  in  Transverse  Positions  of  the  Fetus. — The  defective 
closure  of  the  pelvic  girdle,  so  characteristic  of  the  transverse  po- 
sition, greatly  favors  funic  displacement;  and,  while  prolapse 
occurs  most  frequently  in  this  position,  it  is  the  most  amenable  to 
treatment.  So  long  as  the  sac  remains  intact  there  is  little  dan- 
ger from  pressure,  and  the  condition  requires  no  particular  treat- 
ment other  than  is  recommended  in  any  case  of  cross-birth, — that 
is,  to  prevent,  if  possible,  the  premature  rupture  of  the  amnion  un- 
til the  cervix  becomes  dilated.     The  patient  is  directed  to  remain 

368 


PROLAPSE    OP    THE    UMBILICAL    CORD 


369 


ill  bed,  and  to  refrain  as  much  as  she  can  from  conscious  efforts  to 
deliver  herself.  A  valuable  device  for  holding  back  the  forelying 
cord  is  the  colpeurynter.  If  this  instrument  is  not  at  hand,  the 
vaginal  tampon  may  be  similarly  employed. 

If  cephalic  version  is  performed  (by  external  manipulation,  of 
course),  special  precautions ,, should  be  taken  afterward  to  make 
sure  that  the  cord  does  not  lie  in  front  of  the  advancing  head  be- 
fore rupturing  the  sac. 

In  dealing  with  prolapse  after  the  anniion  has  ruptured,  much 


Fig.  203. — A,  presentation,  or  forelying,  of  the  umbilical  cord,  the  membranes  unruptured. 
B.    Prolapse   of  the   cord,    the  membranes   ruptured. 

depends  on  the  patency  of  the  cervix.  As  far  as  pressure  on  the 
cord  is  concerned,  the  greater  the  dilatation  the  more  is  the  dan- 
ger, since  all  parts,  funic,  as  well  as  fetal,  move  deeper  into  the 
pelvis.  An  open  state  of  the  cervix,  on  the  other  hand,  facilitates 
delivery.  In  one  instance  it  may  be  sufficient  to  ojjserve  the  proc- 
ess of  birth  closely  and  wait ;  in  another,  particularly  if  with  the 
cord  an  arm  has  fallen  down,  pressure  effects  may  make  it  nec- 
essary to  replace  the  dislocated  members  and  keep  them  out  of  the 


370 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


way  of  harm  until  the  uterus  has  opened  sufficiently  to  admit  of  de- 
livery. 


Fig.   204. — Prolapse   of   the   cord.      (Bumm.) 


Prolapse  in  Breech  Presentation. — The  pressure  exerted  on  the 
eord  Ijy  the  soft  and  not  very  voluminous  breech  is  comparatively 


PROLAPSE    OF    THE    UMBILICAL    CORD 


371 


slight,  especially*  if  the  amniotic  sac  is  intact.  By  means  of  pos- 
tural treatment,  such  as  the  exaggerated  Sims,  the  modified  Tren- 
delenburg, or  the  knee-chest  position,  the  cord  will  sometimes  fall 
out  of  the  way  until  the  breech  completely  fills  the  pelvic  girdle. 
If  the  sac  has  ruptured  and  the  cord  fallen,  but  the  cervix  as  yet 
not  fully  dilated,  the  prolapsed  member,  after  being  replaced,  can 
be  kept  from  coming  down  again  by  making  traction  on  the  foot. 
It  is  not  always  possible,  however,  to  get  the  foot,  but,  Avhen  it  is, 


Fig.   205. — Instrunaental    reposition    of   the   cord   by   means    of   a   threaded   catheter.    (After 

Edgar.) 


a  more  favorable  position  for  the  cord  may  be  maintained  by  it ; 
and,  besides,  one  stands  in  a  better  position  to  do  an  extraction 
should  the  exigencies  of  the  case  demand  it.  "When  first  seen,  la- 
bor may  have  reached  a  stage  where  the  breech  lies  low  in  the  pelvis, 
with  the  cord  prolapsed  and  the  cervix  only  partly  dilated.  In 
this  case  the  thing  to  do,  provided  the  cord  is  still  pulsating,  is  to 
incise  the  cervix  and  extract  the  child. 
Prolapse  in  Foot  Presentation. — A  footling,  complicated  with 


372 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


prolapse  of  the  cord,  is  even  less  menacing  than  either  of  the 
foregoing.  No  special  treatment  is  indicated  unless  pressure  mani- 
fests itself,  when,  upon  the  descent  of  the  buttocks,  extraction  can 
readily  be  executed. 


Fig.   206. — De  ail   of  threaded  catheter  with  a  loop  of  thread  entwined  about  the  cord. 

Prolapse  in  Head  Presentations. — While  it  is  true  that  more 
than  one-half  of  all  the  cases  of  prolapse  occur  in  vertex  births 
(Fig.  204),  the  ratio  is  small  as  compared  with  that  of  presentation 
by  the  shoulder  and  breech.     Take  them  as  they  run,  prolapse  oe- 


PROLAPSE    OF    THE    UMBILICAL    CORD  373 

curs  about  once  in  154  births.  Five  of  these  would  present  by 
the  breech,  and  only  one  by  the  shoulder,  yet  25.2  per  cent  of  all 
cases  of  prolapse  are  associated  with  the  breech,  and  17  per  cent 
with  the  shoulder.  The  head,  because  of  its  shape,  size,  and  con- 
sistence, does  not  favor  displacement  of  the  funis,  but  the  danger 
from  pressure  becomes  greatly  increased  in  case  it  should  prolapse. 
If  the  cervix  is  fully  dilated  when  the  displaced  cord  is  discovered, 
nine-tenths  of  the  danger  is  over,  provided,  of  course,  that  the 
cord  has  not  already  suffered  from  pressure.  But,  on  the  other 
hand,  if  when  the  cord  comes  down,  the  effacement  is  only  par- 
tial, the  outlook  for  the  child  is  bad,  no  matter  what  facilities  are 
at  hand. 

In  any  case  some  attempt  should  be  made,  first  of  all,  to  relieve 
the  pressure,  and  to  ascertain  if  the  child  be  alive ;  for  ob- 
viously, it  would  be  useless  to  start  procedures  of  delivery  if  it  be 
dead.  With  the  patient  in  the  knee-chest  posture,  it  may  be  pos- 
sible to  replace  (Fig.  205)  the  cord,  but  should  an  anesthetic  be 
required,  the  Trendelenburg  position  is  better.  One  must  not 
forget  when  palpating  the  cord  that  its  pulsations  may  be  lost  dur- 
ing a  contraction  only  to  return  when  the  pain  has  passed.  If  the 
fetus,  unmistakably,  is  dead,  all  therapeutic  measures,  as  far  as 
the  child  is  concerned,  are  abandoned ;  if  alive,  the  treatment  to  be 
followed  will  depend  on  the  conditions  that  accompany  the  pro- 
lapse. 

TREATMENT 

Before  undertaking  any  procedure  of  relief,  there  are  a  number 
of  things  one  would  Avish  to  know.  For  example,  is  it  the  patient's 
first  or  subsequent  labor?  Will  the  cervix  yield  readily  to  artificial 
dilatation?  Has  the  sac  ruptured,  and,  if  so,  for  how  long!  What 
are  the  facilities  at  hand  for  replacing  the  cord  f 

Generally  speaking,  the  management  of  prolapse  is  more  difficult 
in  the  primipara  than  it  is  in  the  multipara:  the  parts  are  more 
contracted,  the  tissues  offer  greater  resistan(;e,  and  the  patient  her- 
self is  less  responsive  to  the  obstetric  measures  instituted.  But 
more  depends  on  the  condition  of  the  cervix  than  on  any  one  other 
thing.  If  it  is  undilated  and  undilatable,  prolapse  of  the  cord  pre- 
sents a  very  difficult  problem  indeed. 


374  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

In  case  the  sac  has  ruptured  and  the  cord  fallen  outside  the  vulva, 
it  should  be  protected  from  pressure  and  be  kept  warm.  The  pa- 
tient should  remain  quiet  in  bed,  otherwise  her  movements  will  not 
only  disturb  the  means  of  protection,  but  will  also  subject  the  cord 
to  greater  danger  from  pressure.  If  the  cord  continues  to  fall  in 
front  of  the  advancing  part,  it  may  be  possible  to  hold  the  head  at 
the  time  of  a  contraction  until  the  cervix  dilates  and  delivery  be- 
comes possible.  If  the  head  wholly  or  in  large  part  has  already 
entered  the  pelvis,  the  external  os  alone  remaining  to  be  dilated, 
one  may  incise  the  resisting  margin  and  deliver  the  child  with  for- 
ceps. Again,  if  the  cervix  remains  closed  and  the  physician  can 
promise  with  considerable  degree  of  certainty  that  the  result  will 
be  successful  for  l3oth  mother  and  child,  he  may  be  warranted  in 
performing  cesarean  section,  either  abdominal  or  vaginal. 

With  the  head  still  above  the  inlet  of  the  pelvis  (the  most  fre- 
quent situation  in  prolapse)  the  best  treatment,  undoubtedly,  is 
podalic  version  and  extraction.  The  only  rival  procedure  would  be 
cesarean  section,  and  this  only  when  the  life  of  the  child  is  reck- 
oned equal  to,  or  more  important  than  that  of  the  mother.  If  the 
head  has  already  entered  the  pelvis,  delivery  may  be  effected  with 
forceps,  great  care  being  taken  not  to  include  the  cord  in  its  grasp. 

In  prolapse  of  the  cord  there  is  a  variation  from  the  usual  method 
of  performing  version  which  is  worth  remembering,  and  that  is  to 
turn  the  fetus  in  the  direction  opposite  to  that  in  which  it  ordi- 
narily would  be  turned.  If  version  is  made  by  the  shorter  route, 
the  umbilicus  is  brought  nearer  the  pelvic  brim  than  it  was  before, 
thus  favoring  the  further  descent  of  the  cord.  So,  instead  of  push- 
ing the  head  in  the  direction  of  the  fetal  back,  as  is  usually  done, 
it  should  be  pushed  toward  the  chest.  The  umbilicus  will  in  this 
way  be  carried  away  from  the  pelvic  brim.  As  the  leg  is  brought 
down  the  prolapsed  cord  should  be  placed  in  the  posterior  angle  of 
the  oblique  diameter  opposite  to  that  in  which  the  back  of  the  fetus 
lies;  and,  so  long  as  there  is  pulsation,  further  interference  is  not 
necessary.  But  in  case  the  pulsation  stops,  extraction  by  the  foot 
will  have  to  be  made  if  any  hope  is  entertained  of  getting  a  live 
child.  It  may  be  added,  however,  that,  in  any  event,  the  prognosis 
is  bad. 

It  is   always   desirable  to  have   the  patient  lying  instead   of 


PROLAPSE    OF    THE    UMBILICAL    CORD  375 

standing  when  the  sac  ruptures.  Only  when  the  advancing  part 
completely  fills  the  pelvic  girdle  should  a  woman  in  labor  be 
allowed  to  assume  the  upright  position.  Especially  should  this 
rule  be  observed  if  the  stage  of  dilatation  is  well  advanced 
for,  with  the  announcement  that  the  waters  have  broken,  the 
patient  may  add  that  something  is  felt  protruding  from  the 
vagina.  Besides,  standing  favors  the  accumulation  of  the  fore- 
waters,  which  in  themselves  lead  to  the  early  rupture  of  the  sac. 

Should  it  become  necessary  to  rupture  the  amnion  when  in  the 
multipara  the  head  will  not  engage,  it  should  be  done  with  the 
greatest  precaution,  bearing  in  mind  the  possibility  of  a  loop  of 
cord  lying  low  in  the  cavity.  Instead  of  making  a  large  opening 
and  allowing  the  water  to  rush  out  with  force,  a  small  one  should 
be  made,  and  the  fluid  drained  off  slowly.  With  one  hand  applied 
to  the  mouth  of  the  uterus,  the  other  making  counterpressure  on  the 
fetus  externally,  the  amount  can  be  regulated  and  the  cord  kept 
from  slipping  past  the  head.  The  same  precautions  should  be 
observed  in  the  use  of  the  metreurynter.  As  it  is  brought  away, 
the  presenting  part  should  follow  elosel3^ 


CHAPTER  XXVI 

THE   CONTRACTED  PELVIS 

In  the  language  of  De  Lee,  "No  subject  in  medicine  presents 
greater  difficulties  in  all  its  aspects ;  and  none  demands  so  much  art 
and  practical  skill  as  does  the  management  of  labor  in  conditions  of 
pelvic  contraction. ' '  And,  it  may  be  added,  there  is  no  knowledge 
of  the  subject  so  essential  as  a  good  understanding  of  the  mechanical 
principles  involved.  If  the  time  should  ever  come  when  babies  gen- 
erally, instead  of  making  their  advent  per  vias  naturales,  are  lifted 
through  an  abdominal  incision,  little  thought  will  then  need  to  be 
given  to  the  difficult  problems  of  pelvic  deformities.  That  time, 
however,  has  not  yet  arrived,  and  students  of  obstetrics  will  need 
to  go  on  familiarizing  themselves  with  things  as  they  are. 

CLASSIFICATION 

The  following  classification  of  contracted  pelves  (Fig.  207)  is 
simple  and  practical : 

The  Simple  Flat  Pelvis. — This  form  differs  very  little  from  the 
normal,  except  that  the  anteroposterior  diameter  is  foreshortened. 

The  Rachitic  Flat  Pelvis. — The  peculiarity  of  this  form  is, 
that  the  sacrum  is  not  only  pushed  forward,  but  is  rotated  on  its 
transverse  axis. 

The  Generally  Contracted  Pelvis. — This  is  commonly  known 
as  the  j^isto  minor  pelvis.  Strictly  speaking,  it  is  not  a  deformed 
pelvis.  While  it  may  sometimes  be  slightly  asymmetrical,  it  is  es- 
sentially a  normal  pelvis  in  miniature. 

The  Pelvis  Contracted  at  the  Outlet. — This  is  the  so-called- 
funnel-shaped  pelvis,  said  to  be  a  common  form  among  the  white 
women  of  America. 

Oblique  Deformities  of  the  Pelvis. — Such  distortions  come 
from  some  childhood  affection  of  the  knee,  hip,  pelvis,  or  spine. 

376 


THE    CONTRACTED   PELVIS 


377 


The  Coxalgic  Pelvis. — Probably  the  most  common  of  the 
oblique  contractions.  It  is  due  to  unequal  femoral  pressure.  The 
well  side  is  the  one  to  become  distorted. 

Transverse  Contraction. — Not  common. 


Fig.   207. — The  more   common  types  of  pelvic  defonuity  compared   with   the   normal. 


The  Eobert's  Pelvis.^ — A  very  rare  form  of  transversely  con- 
tracted pelvis;  only  ten  cases  recorded. 

The  Kyphotic  Pelvis. — Peculiar  to  the  humpback. 


i78 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


Spondylolisthetic  Pel\'is. — An  exaggerated  lordosis  of  the  lum- 
bar spiue.     (Fig.  208.) 

Osteomalacic  Pelvis. — Unknown  in  America,.  England,  and 
France. 

Justo  Major  Pelvis. — Not  a  deformity,  simply  a  very  large  pel- 
vis. 


Fig.   208. — The   spondylolisthetic   pelvis.      (After   Bumm.) 

Scliroeder  divides  pelvic  contraction  into  three  groups,  ahsolutc, 
relative,  and  moderate.  If  the  true  conjugate  is  below  6.5  cm., 
birth  by  way  of  the  natural  passages  is  impossible ;  the  child  must 
be  delivered  through  the  abdomen.  If  the  same  diameter  is  above 
6.5  cm.  and  below  9  cm.  a  living  child  can  sometimes  be  born  natu- 
rally, a  mutilated  one  always.  A  third  degree  includes  pelves  with 
true  conjugates  of  from  9  cm.  up  to  normal.     These  measurements 


THE    CONTRACTED   PELVIS 


379 


apply  only  to  the  fiat  pelves.     In  the  generally  contracted  pelvis, 
0.5  cm.  should  be  added  to  the  upper  limit  of  each  division. 

The  Rhomboid  of  Michaehs 

When  this  rhomboid  figure  of  the  lumbosacral  region  is  of  average 
size  and  form,  the  pelvic  opening  is  also  said  to  be  of  average  size 


Vig.   209. — Ideal    female    figure    showing    the    rhomboid    of    jNIichaelis. 

and  form.  Its  variation  is  a  registration,  more  or  less  accurate,  of 
the  altered  shape  of  the  inlet.  If,  for  example,  the  lateral  depres- 
sions are  widoly  separated,  the  sacrum  is  broad  and  the  pelvic 
opening  large;  if  close  together,  the  converse  is  true.  The  upper 
point  sometimes  lies  low,  approaching  the  level  of  the  lateral  arms 
of  the  figure.  This  would  indicate  a  pushing  forward  and  down- 
ward of  the  sacrum,  as  would  occur  in  a  rachitic  flat  pelvis  and  in 


380  MANAGEMENT   OF    THE    SERIOUS    COMPLICATIONS 


Fig.  210. — Breisky's  pelvimeter. 


THE    CONTRACTED   PELVIS 


381 


certain  cases  of  spinal  curvature.  Again^  wlien  the  figure  becomes 
distorted,  one  arm  of  the  rhomboid  lying  lower  than  the  other 
and  nearer  to  the  median  line,  it  is  probable  that  the  pelvis  is 
of  the  obliquely  contracted  type. 


Fig.   211. — Female    figure    with   pelvis   and   lines    of    measurement   outlined.      (I^uinm.) 


Pelvimetry 

There  are  many  instruments  and  devices  for  measuring  the  pel- 
vis, some  of  which  are  complicated,  impracticable,  and  expensive. 
For  internal  measurements,  the  hand  is  the  best  pelvimeter.    But 


382 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


hands  vary;  and,  until  the  size  of  one's  hand  becomes  thoroughly 
known,  accuracy  and  uniformity  must  be  acquired  by  means  of  in- 
struments of  precision. 

There  are  not  many  measurements  at  most,  and  but  few  that 


Fig.   212. — Taking  the  interspinal  and  intercristal   measurements. 


need  be  taken.  The  external  ones  are  (1)  the  interspinal,  (2) 
the  intercristal,  (3)  the  intertrochanteric,  (4)  the  external  con- 
jugate, (5)  the  right  and  left  oblique,  and  (6)  the  intertuberal. 
These  are  all  taken  with  the  Breisky  pelvimeter  (Fig.  210). 


THE    CONTRACTED   PELVIS 


383 


External  Measurements 

(1)  The  Interspinal  Diameter  (26  cm.).— This  is  the  distance 
from  the  aiiteriorsuperior  spine  of  the  ilium  on  one  side  to  a  cor- 
responding point  on  the  other  (Fig*.  212). 


Fig.   213. — Measuring  the   external    conjugate. 

(2)  The  Intercristal  Diameter  (29  cm.). — This  is  the  distance 
between  the  crests  of  the  ilia  (Fig.  212). 

(3)  The  Intertrochanteric  Diameter   (32  cm.).- — This  is  the 
distance  between  the  right  and  left  trochanters. 

(4)  The  External  Con.jugate  Diameter  (21  cm.). — This  is  of- 


384 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


ten  referred  to  as  the  diameter  of  Baudelocque,  and  represents  the 
distance  betAveen  the  upper  external  border  of  the  saernm  and  the 
upper  external  border  of  the  symphysis  pubis  (Fig.  213). 


Fig.   214. — Measuring   the  intertuberal   diameter   of   the   outlet. 

(5)  The  Eight  and  Left  Oblique  Diameters  (22  cm.). — This 
measurement  is  taken  from  the  posteriorsuperior  spine  of  the 
ilium  on   one   side  to   the   anteriorsuperior   spine   of   the   other. 


THE    CONTRACTED    PELVIS 


385 


(6)  The  Intertuberal  Diameter  (11  cm.)- — This  is  the  trans- 
verse diameter  between  the  tuberosities  of  the  ischii  (Fig.  214). 

(7)  The  Anteroposterior  Diameter  of  the  Outlet. — This  is 
the  distance  between  the  middle  of  the  pubic  arch  in  front  to  the  tip 
of  the  coccyx  behind,  and  measures  about  12.5  cm.  Two  other 
measurements  of  the  outlet  are  sometimes  referred  to,  namely,  the 


Fig.   215. — Measuring   the    anteroposterior   diameter    of    the    outlet. 

anterior  and  the  posterior  sagittal.  They  are  calculated  from  an 
imaginary  point  where  the  anteroposterior  diameter  of  the  outlet 
bisects  the  intertuberal,  the  distance  from  this  point  to  the  lower 
border  of  the  symphysis  pubis  in  front  being  the  anterior  sagittal 
diameter,  and  the  distance  from  the  same  point  to  the  tip  of  the 
coccyx  in  the  back,  the  posterior  sagittal  diameter.     (Fig.  215.) 


386 


MANAGEMENT    OP    THE    SERIOUS    COMPLICATIONS 


Fig.  216. — Faust's 
pelvimeter  for  the 
direct  measure- 
ment of  the  inter- 
nal conjugate  di- 
ameter. 


Internal  Measurements 

Several  instruments  designed  to  measure  the 
true  conjugate  have  been  devised  (Fig.  216).  In 
order  to  use  them  with  safety  and  accuracy  the 
finger  must  direct  their  introduction  and  adjust- 
ment to  the  points  between  which  measurements 
are  to  be  taken ;  the  promontory  must  be  located 
before  the  internal  end  of  the  pelvimeter  can 
properly  be  placed.  The  query  presents  itself, 
Why  not  measure  with  the  hand  in  the  first  place  ? 
In  fact  the  hand  is  used  much  oftener.  for  pur- 
poses of  pelvic  mensuration  than  any  of  the  me- 
chanical devices.  Fig.  217  shows  the  hand  in  po- 
sition for  measuring  the  obstetric  conjugate.  The 
distance  between  the  ]3oint  where  the  upper  sur- 
face of  the  examining  hand  rests  against  the 
lower  border  of  the  symphysis,  and  the  point  on 
the  promontory  of  the  sacrum  touched  with  the 
tip  of  the  second  finger  of  the  same  hand,  repre- 
sent the  diagonal  conjugate.  The  true  conjugate 
is  approximately  one  and  one-half  centimeters  less 
than  this. 

In  measuring  the  diameters  of  the  outlet  the 
hand  again  becomes  useful.  In  its  application 
here,  it  is  the  closed  fist  instead  of  the  extended 
fingers,  that  is  used  to  measure  with.  The  Breisky 
pelvimeter,  however,  is  more  scientific  and  is  ex- 
ceedingly simjDle  of  adjustment.  Even  a  tape 
measure  or  a  piece  of  string  answers  the  purpose. 

Treatment 


The  indicated  treatment  in  the  more  marked 
contractions  of  the  pelvis  is  definite.  That  is,  the  pelvis  is  so  ob- 
viously contracted  that  birth  can  not  take  place  through  the 
natural  passages,  and  but  one  thing  is  left  to  do,  and  that  is  to 
deliver  by  the  abdominal  route.  In  this  category  belong  pelves 
with  a  true  conjugate  of  5.5  cm.  or  under.  Through  an  opening 
as  small  as  this  even  the  dismembered  child  can  not  be  delivered; 


THE    CONTRACTED    PELVIS 


387 


nor  is  it  possible  in  a  ijelvis  with  the  above  dimensions  to  deliver 
prematurely  Avith  any  hope  of  getting  a  viable  child,  because 
labor  would  need  to  be  brought  on  too  early  to  make  extrauterine 
existence  of  the  fetus  possil)le.  The  delivery,  then,  of  all  cases 
in  this  class,  Avhether  the  child  is  alive  or  dead,  would  have  to  be 
by  cesarean  section. 
In  another  class  of  eases,  wiiere  the  pelvic  contraction  amounts  to 


Fig.   217. — Manual  measurement  of  the  internal  conjugate. 

7  cm.,  a  living  full-time  child  can  not  be  born  by  the  vagina ;  but  it 
may,  however,  be  delivered  bj^  embrj^otomy.  Even  then  it  becomes 
difficult.  A  premature  child,  if  small  enough,  might  pass  after  one 
of  the  operations  designed  to  widen  the  pelvis,  such  as  symphyse- 
otomy and  pubiotomy,  had  been  performed. 

To  know  what  to  do  in  the  tirst  class  of  cases  is,  as  has  been  re- 
marked, easy;  but  in  the  other  group  Avith  the  true  conjugate 
measuring  7  cm.  the  problem  becomes  extremely  puzzling.  If  the 
patient  is  in  the  hospital,  or  can  safely  be  taken  there  at  the  be- 


388 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


ginning  of  labor  and  before  any  examinations  or  attempts  to  de- 
liver have  been  made,  the  child  living  and  at  term,  cesarean  section 
is  indicated.  Under  the  same  circumstances,  except  that  the  child 
is  dead,  perforation  and  cranioclasis  is  the  operation  to  be  per- 
formed. If  the  child  is  living  and  viable,  but  short  of  term,  in- 
duction of  labor  and  pubiotomy  are  to  be  considered. 


Fig.   218. — Cliondrodystrophic    dwarf.       (Ribemont-Dessaignes.) 


A  contracted  pelvis  with  a  true  conjugate  above  7  cm.  is  the  one 
that  perplexes  the  obstetrician  most.  Because  of  its  frequent 
occurrence  in  practice,  and  the  fact  that  a  spontaneous  birth  of  a 
living  child  is  not  impossible,  one  is  often  halted  between  two 
opinions, — Avhether  to  let  alone  or  to  interfere.   Primarily,  it  is  a 


THE    CONTRACTED    PELVIS 


389 


matter  of  degree ;  the  less  the  contraction  the  more  nearly  the  de- 
livery approaches  normal.  AVith  a  true  conjugate  of  9.5  cm.  there 
is  scarcely  any  difference.  Yet  much  depends  on  the  size  and 
plasticity  of  the  child's  head.  The  smaller  and  more  plastic  it  is, 
the  easier  it  will  be  for  it  to  pass  through  the  contracted  pelvis,  so 


Fig.   219. — Simple    rachitic   pelvis.     Twin         Fig.   220.- 
pregnancy.       Cesarean     section.       (Author's 
case.) 


-Colored  woman  with  flat  rachitic 
pelvis. 


that  a  small  child,  a  twin  for  example,  or  a  premature  fetus,  ex- 
periences no  difficulty  getting  through  a  pelvis  of  moderate  con- 
tractions. Again,  if  the  ossification  of  the  cranial  hones  is  not 
greatly  advanced,  the  volume  of  the  head  may  be  decreased  by  com- 
pression and  overlapping  of  its  bones,  thereby  making  birth  rela- 


390  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

lively  easy  as  compared  with  a  more  mature  head,  one  that  is  hard 
and  unyielding.  The  various  presentations  of  the  head  also  play 
an  essential  part.  For  example,  a  brow  presentation,  which  is  not 
generally  counted  to  be  a  favorable  one,  may  in  certain  forms  of 
contracted  pelvis,  be  peculiarly  adapted  to  pass  the  narrowed  con- 
jugate. 

In  the  flat  pelvis  and  its  equivalent  forms,  the  essential  difficulty 
lies  in  the  obstruction  offered  by  the  promontory.  Should  the 
posterior  parietal  bone  become  blocked  by  it,  the  anterior  part  sinks 
into  the  pelvis,  the  posterior  tablet  is  pressed  under  the  anterior, 
and  the  transverse  diameter  of  the  head  is  reduced,  thereby  per- 
mitting the  head  to  enter  the  pelvis.  Thus,  instead  of  the  larger 
diameter  of  the  biparietal,  the  smaller  one  of  the  bitemporal,  which 
is  about  1  cm.  smaller,  enters  the  superior  strait. 

The  generally  contracted  pelvis,  frequently  referred  to  as  the 
pelvic  inlet  by  one  or  the  other  of  its  parietal  eminences.  Which- 
ever one  meets  Avith  opposition  first,  becomes  fixed ;  the  other 
character  becomes  more  impassable  than  the  flat  form,  if  the  true 
conjugate  measures  the  same  in  both  instances.  Most  authorities 
maintain  that  there  is  a  potential  difference  of  at  least  0.5  cm. 
That  is,  the  generally  contracted  pelvis,  we  will  say,  of  8  cm.  offers 
as  much  opposition  as  does  a  flat  pelvis  of  7.5. 

The  most  advantageous  position  is  for  the  head  to  present  at  the 
pelvic  inlet  b}''  one  or  the  other  of  its  parietal  eminences. 
Whichever  one  meets  with  opposition  first,  l^eeomes  fixed ;  the  other 
advances.  If  it  is  the  promontory  that  is  met  with,  the  posterior 
parietal  stops  and  the  anterior  (Fig.  221)  goes  on;  and  if  it  is  the 
symphysis  that  gets  in  the  way,  the  anterior  eminence  will  be  the 
one  to  be  held  back  (Fig.  222).  Molding,  too,  becomes  more  ex- 
tensive where  there  is  contraction;  the  bones  are  forced  to  over- 
lap each  other,  and  the  whole  head  becomes  compressed. 

-  As  scon  as  the  head  in  its  greatest  diameter  has  passed  the 
narrowed  strait  of  the  pelvis,  the  occiput  turns  to  the  front.  From 
this  point  on  descent  does  not  differ  materially  from  the  normal, 
for,  usually,  in  pelves  of  the  flat  type  the  outlet  is  relatively  capa- 
cious. If  one  is  able  to  say,  as  labor  goes  on,  that  the  sagittal  suture 
is  approaching  the  median  transverse  line,  and  that  the  arrested 
parietal  bone  can  be  palpated  in  an  increasingly  larger  area,  there 


THE    CONTRACTED    PELVIS 


391 


is  good  reason  to  believe  that  labor  is  progressing  satisfactorily. 
In  the  obliquely  contracted  pelvis  the  occiput  enters  at  the  ex- 
panded portion  where  the  head  finds  better  accomodations  for  its 
comparatively  broad  biparietal  diameter.  In  the  kyphotic  pelvis 
the  smaller  anterior  part  of  the  head,  instead  of  the  broader  occiput, 
finds  better  accommodation  under  the  pubic  arch ;  and  the  con- 
tracted space  at  the  pelvic  outlet  is  thereby  turned  to  advantage. 


Fig. 


11. — Head-molding.      The    posterior    parietal    bone,    held    by   the    promontory    of    the 
sacrum   as  the   anterior   bone   slides   past   the   symphysis   pubis. 


An  essential  j^art  of  labor,  when  complicated  by  pelvic  contrac- 
tion, is  good  strong  pains;  otherwise  sufficient  molding  of  the 
head  can  not  be  brought  about. 

In  cases  of  labor  complicated  by  contraction  of  the  pelvis,  the 
obstetrician  must  know  and  understand  the  relative  proportional 
value  of  the  mother's  pelvis  to  that  of  the  child's  head,-  otherwise  it 
would  be  impossible  for  him  to  offer  an  opinion  of  much  worth  as  to 
the  probability  of  labor  ending  spontaneously.  An  important  help 
in  this  connection  is  a  knowledge  of  the  patient's  previous  parturi- 


392 


MANAGEMENT    OF    THE    SERIOUS    COMPIJCATIONS 


tional  experiences,  if  she  has  had  any ;  and  the  fact  that  she  already 
has  given  birth  spontaneously  to  a  child  is  of  great  value  in  prog- 
nosticating the  outcome  of  her  present  gestation.  Due  allowance 
should  be  made,  however,  for  the  tendency  of  subsequent  children 
to  become  larger  and  their  heads  harder.  Opposed  to  information 
gained  through  her  is  the  fact  that  women  who  have  passed  through 
the  experience  of  childbirth  are  seldom  in  possession  of  the  true 


1 

4 

k 

. 

-^^. 

\ 

1 

1 

y    I  ^ 

i 

1 

fif 

^t 

:'  7 

_, 

1 

^    1  ~"i 

Fig.   222. — The  anterior  parietal  bone,   held  by  the   symphysis  pubis  as  the  posterior   bone 
slides   over  the  promontory  of  the   sacrum. 

facts.  Instead  of  relying  on  her  statements  alone,  we  must  know  of 
ourselves  or  from  others  Avho  have  attended  her  what  mechanical 
difficulties  were  encountered. 

At  the  beginning  of  labor  the  patient  is  advised  to  seek  her  bed 
in  order  that  the  advancing  part  of  the  fetus  may  not  cause  the 
premature  rupture  of  the  amnion,  which,  in  a  contracted  pelvis, 
favors  more  than  any  other  one  factor,  prolapse  of  an  extremity  or 
cf  the  umbilical  cord.     If  rupture  seems  about  to  occur,  from  the 


THE    CONTRACTED   PELVIS 


393 


presence  of  an  increased  quantity  of  water,  it  may  be  prevented  by 
counterpressure  with  the  eolpeurynter.  Preservation  of  the  sac  is 
desirable  since  the  possibilities  of  infection  are  increased  if  the 
membranes  are  ruptured.  If  one  has  to  deal  with  a  vertex  presenta- 
tion, the  pains  being  regular  and  strong,  so  that  the  birth  seems 
likely  to  end  spontaneously,  the  sac  may  be  ruptured  after  complete 
dilatation  of  the  cervix  has  taken  place.  It  is  only  then  that  the 
real  driving  force  of  the  pains,  with  consequent  molding  of  the 
head,  sets  in.    In  rupturing  the  sac  prematurely,  precaution  should 


Fig.  223. — Molding  of  the  shoulders.  A  study  in  frozen  section  (Zweifel).  The 
mother  died  with  the  child  partly  delivered.  Shows  the  relation  of  the  parts  at  this 
stage  of  labor. 

be  taken  to  prevent  the  cord  from  coming  down  with  the  water. 
To  this  end  the  liquor  amnii  should  be  allowed  to  discharge  itself 
slowly. 

During  the  stage  of  expulsion  there  are  certain  advantages  to 
be  gained  by  putting  the  patient  in  the  Walcher  hanging  position. 
(Fig.  7.)  By  rotating  the  pelvis  in  the  sacroiliac  joint  in  this  way, 
it  is  possible  to  increase  the  conjugate  diameter  about  three-fourths 
of  a  centimeter.  The  posture,  however,  is  too  uncomfortable  to  be 
long  endured.    While  not  so  effective,  some  movement  of  the  joint 


394  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

is  secured  by  placing  a  firm  pillow  under  the  patient's  back  just 
above  the  pelvis  as  she  lies  in  bed. 

Attention  should  be  given  to  the  effect  of  labor  on  the  lower 
segment  of  the  uterus.  Because  of  its  great  attenuation,  there  is 
increased  danger  of  rupture.  The  contraction  ring  becomes 
prominent,  and  takes  a  high  position  in  the  uterus.  Frequent 
and  careful  auscultation  of  the  fetal  heart  must  not  be  neglected, 
for  its  altered  rhythm  and  tone  may  demand  the  peremptory  ter- 
mination of  labor. 

By  no  means  does  every  case  of  labor  in  a  contracted  pelvis  call 
for  interference.  If  the  contraction  is  but  moderate  and  the  child 
is  of  average  size,  if  the  presentation  and  position  are  favorable,  if 
the  pelvis  is  strong  and  effectively  supported  by  abdominal  pres- 
sure, the  greater  i^roportion  of  such  labors  will  terminate  spon- 
taneously and  favorably.  At  any  rate,  nature  should  be  given  every 
possible  chance  to  complete  the  process.  But  just  how  long  one  may 
safely  put  off  "doing  something"  is,  at  best,  rather  indefinite. 
Fixed  rules  are  hard  to  formulate,  so  much  depends  on  the  circum- 
stances of  the  case  in  hand,  the  technical  skill  and  experience  of  the 
operator,  and  the  ripeness  of  his  obstetric  judgment.  Unquestion- 
ably, many  cases  of  contraction  are  handled  surgically  that  would, 
were  they  left  alone,  end  spontaneously.  Just  as  truly,  other  cases 
left  alone  have  ended  disastrously,  which  might  have  been  pre- 
vented by  intervention.  Generally  speaking,  though,  patient  wait- 
ing is  the  safer  policy  to  pursue.  In  the  case  of  a  woman  who  has 
been  through  the  procedure  before,  whose  true  conjugate  measures 
8.5  cm.  or  more,  the  child  large,  and  the  head  refusing  to  engage, 
the  patient  herself  giving  a  reliable  history  of  pelvic  dj^stocia, 
version  and  extraction  are  believed  to  be  indicated.  In  the  hands  of 
an  experienced  obstetrician  the  procedure  is  undoubtedly  a  good 
one,  and  will  always  hold  a  high  place  in  the  therapeutics  of  these 
borderline  cases.  Another,  more  skillful  with  the  forceps,  perhaps, 
would  elect  to  try  instrumental  delivery  instead  of  version. 

There  is  this  to  be  said  of  version,  however,  as  compared  with  high 
forceps,  that,  when  once  the  child  is  turned  and  extraction  has  be- 
gun, there  is  no  alternative  but  to  go  ahead  with  the  extraction  re- 
gardless of  consequences.  With  the  forceps  this  is  not  the  case. 
After  a  reasonable  effort  to  deliver  by  this  means,  other  measures 
may  be  tried;   a  tentative  trial  does  not  pi-eclude   pubiotomy, 


THE    CONTRACTED    PELVIS  395 

cesarean  section,  or  even  version,  should  one  or  the  other  of  these 
operations  subsequently  become  expedient. 

Another  procedure,  one  apt  to  be  overlooked  in  these  days  of 
surgical  ascendenc}^,  is  the  induction  of  premature  labor.  Before 
the  child  has'  become  fully  developed,  while  it  is  yet  able  to  pass 
through  the  pelvis,  premature  delivery  may  permit  the  birth  of  a 
viable  child. 

Still  another  measure,  even  more  prophylactic,  is  to  be  found  in 
the  diet,  especially  during  the  last  two  months  of  pregnancy.  As 
far  as  possible  carbohydrates  are  withheld,  and  liquids  decreased. 
Such  a  diet  is  recommended  by  Prochownik.*  In  following  this 
regimen  it  is  essential  that  the  bodily  condition  of  the  mother  be 
watched  closely,  in  order  that  she  may  not  suffer  from  severe  weak- 
ness. 

A  raiher  frequent  accompaniment,  not  necessarily  a  complica- 
tion, of  contracted  pelvis,  is  a  pendulous  abdomen  with  flaccid 
walls,  which  permits  the  uterus  to  fall  forward.  Because  of 
the  deflected  axis,  such  a  condition  interferes  Avith  presentation ; 
also,  there  is  associated  with  and  largely  responsible  for,  such 
pendulosity,  a  lordosis  of  the  lumbar  vertebrae.  After  labor  has 
continued  for  some  hours  with  the  head  presenting  by  the  pos- 
teroparietal  eminence,  as  it  is  most  likely  to  do,  the  sac  rup- 
tured, and  the  anterior  eminence  refusing  to  enter  the  pelvis, 
version  and  extraction  may  still  be  carried  out. 

The  use  of  forceps  in  contracted  pelvis  comes  into  consideration 
only  when  the  head  has  already  entered  the  pelvis  by  its  greatest 
diameter,  or  is  about  to  enter.  In  contractions  of  the  outlet,  forceps 
avails  nothing  if  the  transverse  diameter  is  less  than  8  cm.  Besides, 
it  is  a  serious  undertaking  and  is  likely  to  end  in  the  loss  of  the 
child.  There  is  also  much  danger  of  rupturing  the  symphysis 
pubis  of  the  mother.  This  is  one  situation  where  perforation  and 
cranioclasis  has  some  right  to  consideration,  even  if.  the  child  is 
alive.  The  chances  are,  that  the  head  will  be  crushed  anyway; 
therefore,  rather  than  drag  it  through  a  contracted  pelvis  at  any 
cost,  one  might  better  perforate. 


*Breakfast:  a  small  cup  of  black  coffee,  100  c.c;  zweiback  or  bread  with  a  little  butter, 
200  gm.  Luncheon:  any  kind  of  meat,  or  fish,  eggs,  green  vegetables,  salad,  cheese. 
Dinner:  same  as  luncheon,  with  addition  of  bread  and  butter,  30  to  50  gm.  Fluids:  as 
much  per  day  as  a  pint  of  water,  or  of  red  or  Moselle  wine,  if  the  patient  is  accustomed 
to  the  use  of  wines.  See  fuller*  discussion  of  this  diet  in  Jour.  Am.  Med.  Assn.,  Oct.  28, 
1911,  p.  1474. 


396  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

In  dealing  with  contractions  of  this  degree  (down  to  8.5  cm.  true 
conjugate)  two  rules,  if  followed,  will  save  many  lives:  (1)  Have 
the  patient  in  the  hospital,  and  (2)  maintain  expectant  support  to 
the  limits  of  safety. 

FURTHER  OBSERVATIONS  ON  CONTRACTIONS 
OF  THE  PELVIS 

With  the  possibility  of  cesarean  section  becoming  necessary,  it  is 
desirable  that  no  examination  be  made  through  the  vagina,  as  it 
adds  greatly  to  the  risks  of  the  operation.  Advancement  of  the 
head  can  be  made  out  externally  and  by  rectal  touch. 

Abnormal  presentations  (breech,  face,  brow,  shoulder,)  are  many 
times  more  frequent  than  in  normal  pelves.  Prolapse  of  the  cord, 
arm,  and  foot  are  also  more  common. 

The  caput  succedaneum  becomes  very  large,  so  that  the  scalp  may 
reach  the  vulva  before  the  head  has  passed  the  superior  strait. 

Exhaustion  may  be  so  great  as  to  result  in  death.  Great  watch- 
fulness, therefore,  is  demanded  lest  mother  or  child  perish  from 
too  long  a  test  of  the  natural  forces.  Two  or  three  careful  examina- 
tions in  the  space  of  five  or  six  hours  will  suffice  to  show  whether  or 
not  progress  is  being  made. 

In  a  contracted  outlet  a  posterior  position  of  the  vertex  is  not 
an  unfavorable  one,  since  the  wide  parietal  part  of  the  head  can 
find  better  accommodation  back  of  the  intcrtubcral  line  than  in 
front  of  it.  In  other  words,  there  is  more  room  along  the  sacrum 
than  under  the  pubes. 

Statistics 

Of  300  cases  of  contracted  pelves  which  in  recent  years  have  been 
dealt  with  at  the  Koenigsberg  Clinic,  258  were  fiat  rachitic  pelves ; 
32,  general  symmetrically  contracted;  7,  obliquely  distorted;  3, 
kyphotic. 

In  the  course  of  birth  the  following  complications  were  noted: 

Premature  rupture  of   the   amnion  53 

Infection  fever  23 

Uterine  inertia                           -  16 

Abdominal  pendulosity  4 

Posterior  parietal  presentation  14 


THE    CONTRACTED    PELVIS  397 

Transverse  position  13 

Face  position  1 

Sinciput  position  2 

Prolapsed  arm  in  vertex  position  3 

Prolapse  of  the  cord  in  vertex  position  19 

Tlireatening  rupture  of  the  uterus  11 

Spontaneous  rupture  of  the  uterus  2 

Old  symphyseal  rupture  1 
"Vaginal   scar   after   vesicovaginal    fistula 

operation  1 

Asphyxia  46 

Besides  these  complications  there  were: 

Eclampsia  2 

Placenta  previa  4 

Premature  detachment  of  the  jjlacenta  2 

Retention  nf  the  placenta  2 

Atony  8 

Operations  performed: 

Induction  of  premature  labor  10 

Rupturing  of  the  amnion  5 

Use  of  the  colpeurynter  5 

Use  of  the  metreurynter  13 
Forceps  (following  Hofmeier 's  impression)     17 

Extraction  12 

Version  and  extraction  48 

External  version  on  the  head  1 

Combined  version                              ■  •"> 

Kristeller's  expression  1 

Perforation  and  cranioclasis  1 0 

Perforation  of  the  after-coming  head  9 

Pubiotomy  17 

Abdominal  cesarean  section  3 

Dilatation  after  Bossi  1 

Cervical  incision  3 

Reposition  of  an  arm  2 

Reposition  of  the  cord  1 

Manual  detachment  of  the  placenta  2 

Uterine  tamponade  after  rupture  1 

Uterine  extirpation  after  rupture  1 

Puncturing  of  a  hydrocephalus  1 

The  mortality  in  the  cases  managed  by  operation  Avas: 
Maternal  2.5  per  cent 

Fetal  30      per  cent 

(Abstracted  from  Haramerschlag.) 


CHAPTER  XXVII 

ECLAMPSIA 

Under  the  head  of  eclampsia,  nothing  but  the  management  and 
treatment  of  the  disease  will  be  considered.  Its  etiology  is  locked 
up  in  too  great  obscurity  to  warrant  here  a  lengthy  discussion  of 
its  causation.  "Whatever  it  may  be  that  leads  to  its  development, 
cure,  in  most  instances,  lies  in  emptying  the  uterus.  How  and 
when  this  shall  be  done  will  form  the  basis  of  this  chapter. 

TREATMENT 

Eclampsia  First  Appearing'  During  Labor. — If  the  mouth  of  the 
womb  is  fully  dilated,  or  nearly  so,  when  the  first  convulsion  occurs, 
labor  may  be  terminated  either  by  version  and  extraction,  the  ap- 
plication of  forceps,  or,  if  the  child  is  dead,  by  perforation  and 
eranioclasis.  In  case  the  cervix  is  not  fully  dilated,  delivery  may 
be  expedited  by  making  one  or  more  incisions  in  the  resisting  os. 
The  disease,  unfortunately,  does  not  always  wait  for  so  favorable  a 
time  to  make  its  appearance.  More  frequently  it  bursts  into  action 
at  or  near  the  end  of  pregnancy  or  just  as  labor  begins,  when  it  is 
not  possible  to  put  such  simple  procedures  into  execution.  It  then 
becomes  necessary  to  do  other  things  which  ought  to  be  undertaken 
only  in  the  hospital.  For  this  reason  one  will  do  well  to  adhere  to 
the  following  rule :  //  eclampsia  makes  its  appearance  during  preg- 
nancy or  at  the  beginning  of  labor,  the  patient  slioidd  at  once  he 
taken  to  the  hospital,  and  a  surgeon  called.  Even  if  the  distance 
is  considerable  or  the  means  of  conveyance  are  lacking  in  comfort, 
the  hospital  is  the  place  for  her,  for  experience  has  shown  that  an 
eclamptic 's  chances  of  recovery  are  better  there  than  at  home.  In 
the  hospital  it  would  be  possible  to  carry  out  that  sovereign  opera- 
tion, cesarean  section,  either  vaginal  or  abdominal ;  but  the  risks 
are  too  great  to  warrant  so  fonnidable  an  undertaking  in  a  private 
house.     Sometimes  the  transference  of  the  patient  is  refused  or,  for 

398 


ECLAMPSIA  399 

some  good  reason,  is  thought  to  he  impracticable.  There  is  then  no 
alternative  but  to  do  the  best  one  can  under  the  circumstances. 
With  the  technic  well  understood  and  the  operation  carefullj^  per- 
formed, the  results  of  artificial  dilatation  of  the  cervix  are  nearly" 
as  satisfactor}'  as  cesarean  section ;  and  artificial  dilatation  is  not 
counted  too  serious  a  procedure  to  be  carried  out  at  home. 

Sometimes  one  may  find  it  expedient  to  dilate  by  means  of  the 
child's  body, — he  may  be  able  to  get  hold  of  a  foot  and  by  making 
traction  thereon  dilate  the  canal  from  above.  The  method,  how- 
ever, has  little  to  recommend  it  other  than  as  a  means  of  saving  the 
mother,  which  usually  is  paid  for  by  the  life  of  the  child.  Another 
and  safer  way  for  both  mother  and  child  would  be  to  dilate  with 
the  metreurynter,  more  definite  use  of  which  is  described  on  pages 
78,  399.  Before  beginning  this  procedure,  it  is  important  that  the 
amnion  be  fii'st  ruptured ;  otherwise  the  added  volume  of  the  bag 
endangers  the  already  distended  uterus. 

Before  undertaking  any  operative  procedure,  exploration,  or  even 
disinfection,  the  patient  should  first  be  narcotized.  To  proceed 
without  anesthesia  would  be  to  excite  needlessly  a  convulsive  seiz- 
ure. And  in  this  connection  it  may  be  remarked  that  clear 
chloroform  is  not  as  safe  an  anesthetic  in  eclampsia  as  a  combina- 
tion of  chloroform,  alcohol,  and  ether,  in  the  proportion  of  three 
parts  of  chloroform  to  one  each  of  the  other  two  ( Billroth 's  Mix- 
ture). 

Eclampsia  Occurring'  During  the  Earlier  Months  of  Preg- 
nancy.— Eclampsia  occurring  before  the  child  is  viable,  may,  in  some 
instances,  be  temporized  with,  and  treated  after  the  method  of 
Stroganoff.  If  the  eclamptic  seizure  is  light,  and  the  mother's 
general  health  good,  one  may,  through  stimulation  of  the  secretory 
functions,  accompanied  by  moderate  narcosis,  succeed  in  curing  the 
attack  and  carrying  the  case  safely  to  term.  The  undertaking, 
however,  is  venturesome,  and  is  to  be  recommended  only  when  the 
conditions  are  exceptionally  favorable.  The  toxic  state  remains  a 
menace  that  can,  on  slight  provocation,  take  an  unfavorable  course. 

While  the  most  effective  therapy  in  eclampsia  is  the  emptying 
of  the  uterus,  there  are  many  additional  things  to  l)e  done  for  the 
patient,  both  protective  and  eliminative.  She  should  be  kept  in  a 
darkened  room  and  where  the  surroundings  are  quiet.     Anything 


400  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

likely  to  irritate  or  excite  should  be  avoided ;  examinations, 
slamming  of  doors,  loud  talking,  jarring  of  the  bed,  are  things  that 
may  precipitate  a  convulsion.  There  should  be  at  hand  something 
to  put  between  the  teeth  to  keep  them  from  biting  the  tongue  when 
the  fit  is  on.  For  this  purpose  a  rubber  wedge  is  perhaps  the  best 
device,  but  a  covered  spoonhandJe  or  a  wooden  clothespin  answers 
the  purpose.  Otherwise  the  patient  should  be  undisturbed  during 
the  seizure.  In  a  long-continued  unconsciousness  the  mouth  should 
be  washed  out  occasionall}^  with  a  mild  antiseptic  lotion. 

For  the  promotion  of  metabolism  and  the  elimination  of  toxins, 
A^arious  measures  are  recommended.  The  hot  bath,  lasting  from 
twenty  minutes  to  half  an  hour  and  followed  with  the  dry  warm 
pack,  causes  profuse  perspiration,  and  thereby  furnishes  one  means 
of  elimination.  The  hot  wet  pack  has  a  similar  though  somewhat 
weaker  sudorific  effect,  but  it  has  the  advantage  of  disturbing  the 
patient  less.  The  blankets  are  left  applied  for  fifteen  or  twenty 
minutes  without  change,  and  the  treatment  continued  for  a  period 
of  an  hour  or  two.  Much  of  the  edematous  fluid  can  be  removed 
.through  the  skin  in  this  way.  Accompanying  this  treatment  500  to 
750  c.c.  of  physiologic  salt  solution  may  be  given  by  hypoder- 
moclysis. 

The  author  is  one  of  those  who  believes  strongly  in  the  therapeu- 
tic value  of  veratrum  viride.  In  a  patient  with  a  full,  high-tension 
pulse,  he  has  found  it  little  short  of  a  specific  as  far  as  controlling 
the  convulsions  is  concerned.  The  initial  dose  may  be  as  high  as  15 
to  20  minims  of  the  tincture,  given  hypoclermically.  The  drug  is 
repeated  in  10  minim  doses  every  thirty  minutes  to  two  hours  until 
the  eclamptic  seizures  have  subsided  for  at  least  six  hours.  The 
instruction  given  the  nurse  is  to  repeat  the  dose  as  often  as  it  may 
be  necessary  in  order  to  bring  the  pulse  down  to  65-70  beats  per 
minute,  and  keep  it  there. 

If  the  somnolence  is  deep,  the  cyanosis  outspoken,  and,  especially, 
if  there  is  a  beginning  edema  of  the  lungs,  a  vein  should  be  opened 
and  300  to  500  c.c.  of  blood  abstracted.  It  is  well  to  follow  the 
venesection  with  hypodermoclysis.  Should  the  symptoms  be  so 
grave  as  to  occasion  tracheal  rales,  the  patient's  head  is  brought 
dver  the  edge  of  the  table  or  bed,  and  the  accumulated  mucus 
swabbed  from  the  mouth  with  gauze  sponges  made  fast  in  a  pro- 
bang.     The  cyanosis  continuing,  inhalation  of  oxygen   (1  liter 


ECLAMPSIA  401 

per  minute)  may  be  continued  indefinitely  or  until  oxygenation  of 
the  blood  becomes  apparent.  In  desperate  states  of  toxemia  the 
respiration  becomes  irregular  and  shalloAv,  or,  perhaps,  ceases  al- 
together. Then  the  pulmotor  and  the  artificial  aeration  of  the  lungs, 
massage  of  the  heart  and  flicking  of  the  body  with  cold  wet  towels 
come  into  use.  At  the  same  time  camphorated  oil  in  ten  minim 
doses  may  be  given  hypoderrnically  or  intravenously  every  half 
hour.    Digitalin  is  another  serviceable  drug  of  similar  action. 

One  must  be  particularly^  exact  concerning  the  amount  of  urine 
secreted  in  eclampsia.  It  will  hardly  do  to  depend  on  the  state- 
ments of  the  patient  herself  as  to  how  much  water  she  passes.  Such 
information  should  be  obtained  through  catheterization  of  the  blad- 
der. An  attempt  to  restore  the  activity  of  the  kidneys  is  made 
through  hypodermoclysis,  as  much  as  1,500  c.c.  of  normal  saline  be- 
ing introduced  subcutaneously.  Failing  thereby  to  relieve  the  neph- 
ritic tension,  decapsulation  of  the  kidneys  may  be  considered. 

It  is  not  unusual  in  practice  for  one  to  be  in  a  position  to  deal 
prophylactically  with  conditions  that  threaten,  and  to  apply  meas- 
ures in  anticipation  of  an  outburst  of  eclampsia.  Especially  should 
a  patient  with  nephritis  be  under  close  observation,  and  explicitly 
directed  as  to  kidney  conservation. 

MORTALITY 

In  studying  the  statistics  of  eclampsia  the  mortality  appears  to 
be  highest  when  labor  has  been  allowed  to  pursue  its  own  course. 
The  death-rate  in  such  cases  runs  as  high  as  forty  per  cent.  The 
next  highest  rate  is  found  in  a  class  of  cases  where  labor  is  per- 
mitted to  go  on  si)ontaneously  up  to  the  point  of  full  cervical  dila- 
tation, when  forceps,  version,  or  some  other  operative  means  of  de- 
livery is  employed.  The  best  results,  however,  follow  the  rapid 
emptying  of  the  uterus,  either  by  means  of  the  vaginal  cesarean 
section  or  the  rapid  dilatation  of  the  cervix  as  described  herein 
under  the  head  of  ' '  Cervical  Dilatation. ' '  The  mortality  in  a  series 
of  several  hundred  cases  dealt  with  in  this  way  was  not  above  13.5 
per  cent,  with  a  slightly  better  percentage  for  section  than  for 
dilatation. 


CHAPTER  XXVIII 

BIRTH  COMPLICATED  BY  TUMORS 

The  increased  supply  of  blood  to  the  parts,  the  stimulated  metab- 
olism, and  other  impulses  of  growth — all  have  an  effect  during  preg- 
nancy to  bring  about  changes  in  the  genitalia.  Most  of  these 
changes,  however,  are  transitory ;  but  occasionally  tumorous  forma- 
tions take  birth,  and  old  ones  receive  new  life.  The  essential  thing 
about  such  growths,  as  far  as  we  now  are  concerned,  is  not  so  much 
the  alteration  they  undergo  through  the  influence  of  childbirth 
as  the  obstruction  they  offer  to  the  process  of  birth  itself.  We  shall, 
therefore,  look  at  the  subject  mainly  from  this  point  of  view. 

OVARIAN  TUMORS 

An  ovarian  tumor  becomes  an  obstruction  to  birth  Avhenever  it 
obtrudes  itself  on  the  birth  canal,  which  it  may  do  if  it  becomes 
pedunculated  (Fig.  224). 

The  treatment  is  usualh'  one  of  replacement.  If  this  is  not 
possible,  the  tumor  must  be  removed  by  operation.  The  attempt 
to  restore  it  to  the  abdominal  cavity,  however,  should  not  be  aban- 
doned before  making  a  thorough  trial  under  narcosis.  Not  succeed- 
ing w^ithout  it,  the  patient  should  be  anesthetized,  placed  in  the 
Trendelenburg  position,  and  the  whole  hand  introduced  into  the 
vagina.  The  danger  of  rupturing  the  cyst  or  of  tearing  it  loose 
from  its  pedicle,  must  be  borne  in  mind,  for  such  an  injury  compli- 
cates matters  considerably,  both  by  hemorrhage  and  by  infection. 

Failing  to  get  the  tumor  out  of  the  way  by  means  of  manipulation, 
surgical  procedures  become  necessary.  This  means  that  the  abdo- 
men must  be  opened,  and  an  ovariotomy  performed.  If  the  tumor 
is  found  to  be  adherent  and  the  pelvis  small,  the  child  should  first 
he  delivered  by  a  hysterotomy  and  the  tumor  removed  afterward. 
To  do  otherwise  would  make  it  necessary  to  turn  the  pregnant 
uterus  out  of  the  abdomen  and  flex  it  strongl.y  over  the  sym- 
Ijhysis,  which  would  probably  result  in  the  loss  of  the  child.    Even  if 

■402 


felRTH    COMPLICATED    BY    TUMOftS 


403 


the  child  is  dead,  it  is  better  to  reduce  the  size  of  the  uterus  by 
section  before  proceeding  with  the  ovariotomy.  The  attempt  to  re- 
move an  ovarian  tumor  from  below  should  be  made  only  when  it  is 
soft  and  free  from  adhesions,  and  lies  in  front  of  the  cul-de-sac. 
The  operation  then  becomes  comparatively  simple  through  a  pos- 
terior colpotomy. 

A  tumior  of  the  ovary  can  be  removed  during  gestation  without 
very  great  risk  of  interrupting  the  pregnancy ;  and  it  should  be  re- 
moved.   Not  to  remove  it  is  inadvisable  because  of  the  danger  that 


Fig.    224. — Ovarian   cyst   obstructing  birth. 


accompanies  the  stretching  and  twisting  of  its  pedicle,  not  to  men- 
tion the  complications  that  may  arise  from  it  at  time  of  labor. 

Ovariotomy  performed  at  this  time  has  no  greater  mortality 
than  at  other  times  (4  per  cent  to  5  per  cent).  The  usual 
history  of  an  ovarian  tumor  of  pregnancy  is  somewhat  as 
follows :  In  the  third  month  of  pregnancy  an  unaccountable  pain 
in  the  abdomen  is  complained  of,  and  the  patient  herself  will  prob- 
ably surmise  that  something  unusual  is  developing  because  of  the 
peculiar  swelling  in  one  side  of  the  abdomen.  Upon  consulting  her 
physician  a  cystic  tumor  attached  by  a  pedicle  to  the  uterus  will  be 
found.  Convalescence  following  operation  is  usually  rapid,  preg- 
nancy goes  on,  and,  in  due  time,  Inrth  takes  place. 


404 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


UTERINE  MYOMATA 

In  considering  the  influence  myomata  may  haA^e  on  birth,  it  is 
well  to  divide  such  growths  into  those  of  the  upper  and  those  of 
the  lower  segments  of  the  uterus.     Obviously,  only  those  of  the 


Fig.   225. — A  large  myoma  complicating  pregnancy.      (Runge.) 

latter  sort  can  become  obstructive.  The  influence  of  the  other  is 
mechanical,  but  only  in  the  sense  that  it  can  cause  an  unfavorable 
position  of  the  child.  Owing  to  the  disturbed  uterine  contrac- 
tions, such  a  tumor  has  the  further  effect  of  prolonging  labor;  and 
in  the  third  stage,  especially  if  the  placenta  has  its  attachment  over 


BIRTH    COMPLICATED   BY    TUMORS 


405 


the  myomatous  area,  expulsion  may  be  considerably  delayed  (Fig. 
225).  On  the  other  hand,  myomata  may  occasion  so  little  trouble 
during-  parturition  that  they  are  not  discovered  until  afterward. 
Their  presence  is  frequently  confused  with  parts  of  the  child,  and 
can  be  distinguished  from  them  only  by  painstaking  examination. 
So  far  as  pregnancy  itself  is  concerned,  myomata  of  the  uterus 
seldom  demand  attention,  though  such  tumors  may  sometimes  be 
serious   enough   to    require   independent   surgical   treatment.      It 


Fig.   226. — A   submucous  myoma  of  the  lower  segment   of  the   uterus  lying  in   advance   of, 
and   acting   as   an    obstruction  to,   the   head.      (Kerr.) 

should  be  the  aim  of  the  obstetrician,  however,  to  preserve  the  prod- 
uct of  conception  whenever  possible.  The  submucous  myoma,  like 
a  polypus,  protrudes  from  the  uterus  in  front  of  the  advancing 
child,  and  is  easily  removed.  If  the  pedicle  is  thin,  the  passage  of 
the  head  mil  probably  tear  it  loose.  The  interstitial  and  subserous 
myoma,  on  the  other  hand,  can  become  exceedingly  troublesome, 
even  obstructive.  (Fig.  226).  Not  uncommonly,  though,  the  tu- 
mor is  so  small  that  the  uterus  will,  as  its  lower  segment  recedes. 


406  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

pull  the  growth  along  Avith  it  to  a  point  of  safety  above  the  brim, 
where  it  becomes  flattened  out  sufficiently  to  allow  the  child  to  pass. 
If  such  a  tumor  moves  the  other  way,  that  is,  remains  in  the  pelvis, 
its  removal  becomes  necessary  before  birth  can  go  on.  With  the  pa- 
tient in  the  knee-chest  position,  or  lying  on  the  back  with  hips 
elevated,  the  whole  hand  of  the  surgeon  is  passed  into  the  vagina, 
and  moderate  pressure  made  with  it  on  the  tumor,  the  object  be- 


Fig.    227. — An    obstructing   myoma.       (Bumm.) 

ing  to  force  the  obstructive  object  above  the  inlet.  The  peduncu- 
lated subserous  myoma  is  most  favorable  for  reposition  (Fig.  227). 
But  if  it  can  not  be  reduced,  laparotomy  becomes  necessary:  the 
tumor  is  enucleated,  the  Avound  is  closed,  and  the  child  delivered 
naturally.  As  in  the  case  of  ovarian  tumor,  it  may  he  advisable, 
because  of  the  difficulties  encountered,  to  first  deliver  the  child 
through  section  of  the  uterus.     After  the  incision  is  closed,  myo- 


BIRTH    COMPLICATED    BY    TUMORS  407 

mectomy  becomes  easier  to  perform  and  the  child  is  out  of  dan- 
ger. The  tumorous  growths  may  be  so  extensive  as  to  warrant 
hysterectom}' ;  and,  besides,  there  may  be  an  infection  of  the  uterus 
to  consider. 

CARCINOMA  OF  THE  UTERUS 

Carcinoma  of  the  uterus  complicated  by  pregnancy,  or  preg- 
nancy complicated  by  carcinoma  of  the  uterus, — it  is  difficult  to  say 
which  of  the  two  is  the  complication, — constitutes  a  very  unfavor- 
able and  serious  condition.  Proliferation  is  so  rapid  under  the  in- 
fluence of  gravidity  that  a  carcinoma  which  before  was  operable 
soon  becomes  inoperable.  This  might  not  be  so  true  if  the  car- 
cinoma were  of  the  body  of  the  uterus,  but  conception  does  not 
occur  under  such  circumstances;  it  can  exist  only  when  it  is  the 
cervix  that  is  involved. 

A  carcinoma  during  pregnancy  is  treated  precisely  the  same  as 
it  would  be  at  any  time.  If  operable  at  all,  the  procedure  should  be 
radical  and  immediate.  Undoubtedly  the  most  satisfactory  method 
is  to  operate  through  the  abdomen,  completely  removing  the  uterus, 
the  parametrium,  and  the  vault  of  the  vagina.  If  gravidity  is  of 
the  first  few  months,  hysterectomy  can  readily  be  done  without  first 
opening  the  uterus ;  but  in  the  later  months  the  fetus  should  be  de- 
livered first,  especially  if  there  is  any  possibility  of  its  living. 

The  abdominal  operation,  as  compared  with  the  vaginal,  is  ac- 
companied by  a  slightly  higher  primary  mortality,  but  otherwise 
it  is  the  more  satisfactory  procedure  of  the  two.  As  to  whether 
the  uterus  shall  first  be  opened  and  the  fetus  removed  depends  on 
the  time  of  pregnancy,  and  the  preferences  of  the  operator. 

In  the  other  class  of  cases,  that  is,  the  inoperable  carcinoma,  the 
welfare  of  the  child  alone  is  considered ;  but  at  the  same  time  the 
mother's  condition  is  kept  at  as  high  a  level  as  possible.  Marked 
local  fetor  is  treated  with  disinfecting  and  deodorizing  douches  of 
potassium  permanganate  or  hydrogen  peroxide,  or  by  insufflations 
of  some  such  powder  as  dermatol.  Severe  bleeding  may  require 
cauterization  of  the  cancerous  surfaces.  This,  however,  would  be 
very  likely  to  interrupt  pregnancy,  and  should  be  done  only  in  ex- 
ceptional cases.  The  final  delivery  should  always  be  through  ab- 
dominal section ;  to  undertake  it  through  the  vagina  would  be  much 
more  difficult,  as  well  as  more  dangerous. 


408 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


TUMORS  OF  THE  VAGINA  AND  VULVA 

Earely,  yet  often  enough  to  deserve  consideration,  birth  mar  be 
obstructed  by  tumors  of  the  vulva  and  vagina.  Cysts,  solid  tumors, 
especially  the  fibroma  and  fil^romyoma,  carcinoma,  and  even  swell- 
ings, such  as  edema  and  varicosities,  may  be  of  sufficient  size  and 
importance  to  present  a  very  formidable  barrier.  A  vaginal  cyst  is 
seldom  large  enough  to  be  seriouslv  in  the  way :  but  when  it  is,  it 


Fig.   228. — Edema   of  the  vulva. 


should  preferably  be  removed  before  labor,  for  otherwise  it  Avill 
need  to  be  punctured  during  labor.  Solid  tumors,  if  they  reach 
considerable  size,  can  be  enucleated  intrapartum. 

Edema  of  the  vulva  can  be  so  great  that  not  only  is  the  passage 
of  the  child  made  difficult,  but  the  tissues  themselves  become  so 
overstretched  that  their  elasticity  is  gone  and  laceration  occurs 
easily  (Fig.  228).  Scarification  would  better  be  performed  be- 
fore labor  begins,  but  it  may  be  done  at  any  time. 

Other   troublesome    swellings    arise    from    gonorrheal    infection, 


BIRTH    COMPLICATED    BY    TUMORS  409 

such  as  the  formation  of  an  abscess  in  the  vulvovaginal  glands. 
This  would  not  act  seriously  as  an  obstruction,  but  it  might  be- 
come a  focus  of  infection.  To  escape  this  danger  the  cyst  should  be 
cured,  when  possible,  before  labor  comes  on,  for  eventually  it  will 
have  to  be  incised  and  packed.  During  labor  it  is  treated  with 
antiseptic  applications,  in  order  to  prevent  as  far  as  possible 
spreading  of  the  infection.  Condylomata  about  the  vulva  and 
perineum  may  attain  the  size  of  a  fist,  and,  because  of  their  sinu- 
osities, become  sources  of  infection.  Moreover,  such  growths  greatly 
interfere  with  the  elasticity  of  the  parts,  and  should  be  destroyed 
during  pregnancy.  Where  a  patient  comes  to  labor  with  such 
masses  about  the  vulva,  all  that  can  be  done  is  to  keep  them  dis- 
infected as  well  as  possible. 

Varicose  veins  are  often  of  considerable  size,  but  seldom  become 
obstructive.  If  they  rupture,  severe  hemorrhage  may  result,  and 
thus  make  numerous  ligations  necessary. 

A  number  of  other  and  intrinsic  conditions  can  also  act  as  bar- 
riers. A  carcinoma  of  the  rectum,  for  example,  can  be  so  extensive 
as  to  make  cesarean  section  imperative.  A  large  stone  in  the  blad- 
der or  an  extrauterine  lithopedion  has  in  the  same  way  been  known 
to  effectively  prevent  natural  birth. 


CHAPTER  XXIX 

MALFORMATIONS  AND  ANOMALIES 

MALFORMATIONS  AND  ANOMALIES  OF  THE 
MATERNAL  SOFT  PARTS 

Pregnancy  in  a  double  uterus  occasions  little  trouble  unless  an 
obstructing-  ledge  of  tissue  projects  into  the  birth  canal.  It 
could  then  interfere  with  the  performance  of  version,  and  add  to 
the  difficulties  of  the  third  stage.  Nor  does  pregnancy  in  a  bicor- 
natc  uterus  cause  serious  interference  with  birth.  It  behaves  like 
a  normal  pregnancy  except  that  it  may  favor  an  abnormal  presen- 
tation of  the  child.  The  empty  horn  may  become  obstructive  much 
the  same  as  a  subserous  myoma.  A  vaginal  septum  is  pressed  to 
one  side,  but  if  it  should  stand  in  the  way,  it  can  easily  be  re- 
sected between  ligatures.  In  like  manner  other  malformations  and 
contractions  may  block  the  wa3\  Scar  tissue,  for  example,  is  some- 
times so  unyielding  that  the  child  can  not  get  past  it ;  and  even 
the  hymen  offers  considerable  resistance  at  times. 

MALFORMATIONS  AND  ANOMALIES  OF  THE  CHILD 

Anencephalus. — This  relatively  frequent  malformation  (Fig. 
229)  offers  very  confusing  diagnostic  features,  especially  when 
the  head  is  the  part  that  presents:  abdominal  palpation  reveals 
nothing  characteristic,  and  a  vaginal  examination  is  often  mislead- 
ing. 

It  is  characteristic  of  an  anencephalic  monster  that  the  shoulders, 
more  than  the  head,  are  the  parts  most  difficult  to  deliver.  If  the 
obstetrician  is  not  able  to  bring  them  down  with  the  fingers,  he 
can  not  be  condemned  if  he  uses  the  blunt  hook;  and,  in  case  it 
becomes  necessary  to  remove  an  arm  or  sever  the  clavicle,  he  need 
have  no  compunction  about  doing  it,  for  the  child  can  not  live  any- 
way.   The  shoulders  also  cause  trouble  when  such  a  fetus  is  born  in 

410 


MALFORMATIONS   AND    ANOMALIES 


411 


the  breech  position.  But  one  can  not  then  proceed  with  so  little  re- 
gard for  the  safety  of  the  child,  because  the  malformation  is  not 
discoverable  until  the  head  is  born. 

Hydrocephalus. — This  is  a  more  serious  complication  than  aneii- 
cephalus.  The  maternal  mortality  is  not  far  from  20  per  cent, 
a  large  proportion  of  the  deaths  being  due  to  rupture  of  the  uterus. 
The  gravity  of  the  condition  would  not  be  so  great  if  the  diagnosis 
of  hydrocephalus  could  be  made  earlier.  There  are  so  few  symp- 
toms of  the  disease  that  one  does  not  suspect  it  until  after  labor 
has  seriously  weakened  the  uterine  muscle.     (Fig.   230.) 


Fig.   229. — Anencephalus. 

The  hydrocephalic  head,  unless  it  is  of  mild  degree,  can  not  be 
born  without  first  being  emptied  of  its  contained  fluid,  which  may 
be  done  with  a  trocar,  perforator,  or  other  instrument  passed  into 
the  head  between  the  widely  separated  bones  or  through  a  fontanel. 
After  the  water  has  drained  away,  the  pains  usually  become 
stronger,  and  yery  often  birth  goes  on  normalh^  If  birth  does  not 
progress  as  it  should,  a  dose  of  pituitary  extract  ought  to  be  tried 
before  resorting  to  further  operative  measures.  The  forceps  is  of 
little  or  no  advantage,  because  of  the  collapsed  state  of  the  head, 
so  that  other  instruments,  such  as  bone  forceps  or  the  cranioclast, 


412 


MAXAGEMEXT    OF    THE    SERIOUS    COMPLICATIONS 


are  preferable.  Sometimes  the  osseous  structures  of  the  head  give 
way,  and  have  to  be  removed  piece  by  piece,  after  which  an  arm 
can  be  brought  down  and  the  body  extracted.  If  preferred,  a  claw 
forceps  may  be  fastened  to  the  most  secure  place  in  the  parts  pre- 
senting, a  weight  attached,  and  the  fetus  delivered  by  a  slower 
process.  Version  and  extraction  is  rarely  indicated.  One  may  at- 
tempt to  deliver  a  hydrocephalus  of  mild  degree  with  forceps,  but 
the  instrument  must  be  used  with  great  caution,  for  the  blades 


Fig.  230. — Hydrocephalus.     (Bumm.) 


easily  slip  ofif  the  head,  and  in  doing  so  may  cause  much  injury  to 
the  mother  from  their  violent  and  untimely  action. 

A  hydrocephalic  head  coming  last  always  requires  to  be  per- 
forated, the  operation  being  somewhat  more  difficult  than  when 
the  head  presents  (Figs.  231  and  232).  Occasionally  there  is  a 
coexisting  spina  bifida,  through  which  a  catheter  may  be  passed 
into  the  meninges,  and  paracentesis  thus  effected.  Otherwise 
perforation  is  performed  in  the  usual  way. 

Hydromeningocele  and  hydroencephalocele  offer  the  same  ob- 
stacles to  birth  and  demand  the  same  treatment.  To  diagnose  these 
conditions  before  birth,  however,  is  extremely  difficult. 


MALFORMATIONS    AND    ANOMALIES 


413 


As  stated  above,  the  outlook  for  the  mother  in  these  "water- 
head"  babies  would  be  better  if  the  diagnosis  could  be  made  earlier. 
This,  unfortunately,  can  not  often  be  done  bv  the  ordinary  bi- 
manual examination,  especially  if  the  fetus  presents  by  the  breech, 
as  it  so  commonly  does  in  this  condition.  The  whole  hand  must 
first  be  passed  into  the  uterus,  and  the  abnormal  size  of  the  head 


231. — Draining-  off  the   water   from   a  hydrocephalic   head   by   means    of  a  catheter   in- 
troduced through  a  puncture   in   the  spine. 


v.ith  its  wide  sutures  and  fontanels  made  out.  And,  surely,  one 
should  not  undertake  paracentesis  without  first  having  done  this. 
Teratoma  of  the  Body. — Delivery  can  sometimes  be  made  ex- 
ceedingly difficult  through  accumulations  of  fluid,  and  from  other 
anomalous  formations  of  the  fetus.  Even  after  the  head  or  breech 
is  born,  further  delivery  may  become  impossible  unless  such  growths 
be  removed.     Chondrod3^stroiDhia  fetalis,  or  fetal  rickets,  for  ex- 


414 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


ample,  is  a  condition  that  can  be  so  extensive  as  to  require  opera- 
tive intervention  before  birth  can  be  completed. 

Double  Monsters. — The  birth  of  such  an  anomal}^  as  the  double 
monster  mav  lose  its  obstetric  significance  because  of  the  underde- 


Fig.    232. — Cross    section    of   Fig.    232.      {American    Text  Book    of   Obstetrics.) 

velopment  of  the  monstrosity.  Frequently  the  birth  of  such  a  fetus 
is  premature,  though  instances  are  on  record  of  such  children  be- 
ing born  at  term  and  then  onlj^  upon  performing  cesarean  section. 
The  rarity  of  the  condition  makes  the  diagnosis  particularly  diffi- 
cult.    In  one  case  known  to  me,  a  double  monster  was  diagnosed 


MALFORMATIONS    AND    ANOMALIES  415 

as  twins.  Finding  it  impossible  to  deliver  with  forceps,  althongh 
the  pelvic  diameters  were  large,  cesarean  section  ultimately  became 
necessary.  Precise  rules  to  govern  such  cases  can  not  be  laid  down. 
To  sacrifice  a  child's  life  is  always  deplorable,  yet  one  would  be 
justified  in  performing  embryotomy  if  one  could  be  certain  of  hav- 
ing a  monstrosity  to  deal  with.  This  is,  as  has  been  stated,  not 
easily  made  out,  and  the  diagnosis  admits  of  manv  mistakes. 


CHAPTER  XXX 

SPONTANEOUS  ABORTION 

Spontaneous  premature  interruption  of  pregnancy  oftentimes 
carries  with  it  conditions  and  consequences  that  make  operative 
procedures  necessary.  The  nearer  to  term  the  interruption  occurs, 
the  less  deviation  from  normal  is  the  process  of  expulsion.  Con- 
versely, the  earlier  in  pregnancy,  the  more  frequent  are  the  vari- 
ations, particularly  if  the  interruption  occurs  within  the  first  tri- 
mester. The  small  size  of  the  embryo  and  the  undeveloped  state 
of  the  uterus  tend  to  make  spontaneous  expulsion  difficult  and  sur- 
gical interference  necessary.  The  natural  forces,  however,  should 
first  be  given  a  fail  trial. 

DIAGNOSIS 

The  appearance  of  blood  in  the  early  months  of  pregnancy  is 
suggestive  of  abortion ;  accompanied  by  pain,  it  becomes  more  so. 
Whether  pregnancy  is  about  to  terminate  depends  on  the  charac- 
ter of  the  pain,  and,  to  a  lesser  degree,  on  the  amount  of  blood.  The 
regular  occurrence  of  uterine  contractions  with  increasing  fre- 
quency and  severity  is  further  indication  that  an  abortion  is  taking 
place;  and  bright  blood  in  any  considerable  quantity  means  the 
detachment  of  the  embryo.  When  the  blood  is  of  a  brownish  tinge 
and  is  mixed  with  mucus,  it  is  more  indicative  of  an  affection  of 
the  endometrium  or  of  the  ovum  itself.  The  pain  and  bleeding 
is.  followed  b}^  dilatation  of  the  internal  os.  A  patulous  state  of 
the  external  os  in  the  multipara  has  little  significance,  but  in  the 
primipara  it  may  have  considerable.  Having  made  the  diagnosis  of 
impending  abortion,  it  becomes  necessary  to  determine  how  far 
it  has  advanced,  since  its  further  management  depends  thereon. 

A  very  common  classification  of  abortion  is  as  follows:  (1) 
threatened,  (2)  inevitable,  (3)  incomplete,  and  (4)  complete. 

Threatened  Abortion. — An  abortion  is  said  to  threaten  when 
there  is  only  pain  and  hemorrhage.    At  this  stage  it  is  sometimes 

416 


SPONTANEOUS    ABORTION  417 

possible  to  prevent  the  abortion  going  further.  The  patient  should 
remain  in  bed,  and  the  attempt  be  made  with  opiates  to  quiet  the 
uterine  activity.  For  this  purpose  half -grain  suppositories  of  codein, 
given  per  rectum  every  four  hours,  are  recommended.  Teaspoonful 
doses  of  viburnum  prunifolium,  given  three  times  a  day,  is  be- 
lieved to  have  a  good  effect  in  preventing  abortion.  Local  treat- 
ment of  any  sort  is  contraindicated. 

Inevitable  Abortion. — The  ovum  is  here  still  intact,  but  the 
internal  os  has  opened  so  that  with  the  finger  one  can  feel  the 
round  structure  of  the  ovum  in  the  uterus.  There  is  also  to  be 
made  out  at  this  time  a  peculiar  succulence  of  the  uterus,  due  to 
the  congested  state  of  the  organ.  A  foul-smelling  discharge  soon 
follows,  especiall.y  if  the  ovum  has  been  infected. 

An  abortion  that  has  gone  thus  far  can  not  1)e  arrested ;  but  it  is 
perfectly  proper  to  allow  the  natural  forces  to  complete  the  proc- 
ess, and  only  in  exceptional  cases,  where  the  hemorrhage  is  severe 
or  the  discharge  particularly  foul,  is  it  necessary  to  remove  the 
ovum. 

Incomplete  Abortion. — It  is  the  incomplete  form  of  abortion  that 
most  frequently  requires  surgical  treatment,  since  in  these  cases 
portions  of  the  retained  ovum  need  to  be  removed  from  the  cavity 
of  the  uterus.  It  is  impossible  to  say  how  much  is  yet  remaining, 
particularly  if  the  cervical  canal  is  contracted.  Sometimes  one  is 
fortunate  enough  to  have  had  saved  for  his  inspection  all  that 
comes  away.  He  can  then  judge  of  its  completeness.  With  the 
cervix  dilated  wide  enough  to  admit  the  examining  finger,  confir- 
mation becomes  relatively  easy. 

Complete  Abortion. — An  abortion  is  said  to  be  complete  when  the 
uterus  has  returned  to  its  normal  size  and  hardness.  As  already 
stated,  the  spontaneous  completit)n  of  an  abortion  is  the  most  favor- 
able course  for  it  to  pursue, — either  the  expulsion  of  the  ovum  in 
toto,  or  first  the  embrj^o  and  then  the  placenta.  This,  however,  does 
not  always  occur.  Left  entirely  to  itself,  the  process  may  extend 
over  weeks  or  even  months,  and  be  accompanied  by  great  loss  of 
blood.  The  bleeding  from  a  prolonged  incomplete  abortion,  though 
seldom  the  immediate  cause  of  death,  can  be  the  occasion  of  a  severe 
anemia  that  ultimately  may  lead  to  death.  The  amount  of  blood  lost 
and  its  consequences,  therefore,  constitute  no  inconsiderable  part  in 
the  prognosis.     The  bodily  temperature  and  discharges  must  be 


418  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

watched  closely  for  any  signs  of  infection,  especially  if  the  abortion 
is  treated  expectantly.  Surgical  interference  becomes  necessary 
whenever  the  retained  ovnm  ceases  to  be  innocuous  or  the  sponta- 
neous completion  of  the  process  does  not  follow  in  a  reasonably 
short  time.  A  criminally  induced  abortion,  as  compared  with  the 
spontaneous,  is  of  much  more  serious  import,  because  of  the  non- 
aseptic  conditions  under  which  it  is  commonh^  performed.  In  the 
presence  of  a  genital  lesion  there  may  follow  a  true  septic  proc- 
ess, such  as  a  metrophlebitis  or  a  parametral  exudate;  and,  as  Ave 
know,  it  sometimes  ends  in  general  septicemia  and  death. 

A  simple  saprophytic  process  does  not  necessarily  demand  treat- 
ment, yet  it  is  considered  proper  to  clean  out  the  uterus ;  but  much 
depends  on  the  circumstances,  surroundings,  and  conditions  under 
which  it  is  done,  for,  in  removing  the  decomposing  ovum,  which  in 
itself  may  not  be  dangerous,  other  and  more  virulent  germs  may 
be  introduced,  or  an  infection  that  has  remained  inactive  may  be- 
come lighted  up  by  intrauterine  manipulations.  Therefore,  as  lit- 
tle local  investigation  as  possible  should  be  undertaken,  and  what- 
ever is  done  should  be  done  surgically  and  thoroughly.  To  pro- 
long any  of  the  procedures  is  to  encourage  infection. 

On  the  other  hand,  an  infection  may  have  already  gone  beyond 
the  walls  of  the  uterus,  even  into  the  l:)lood  stream.  It  then  becomes 
impossible  to  remove  more  than  a  part  of  the  infectious  substance, 
and  imprudent  to  attempt  it.  ]Much  manipulation  serves  only  to 
force  the  infection  further  into  the  tissues.  Such  an  instance  is 
the  following,  which  is  by  no  means,  unique : 

A  young  "n-oman  in  the  fourth  month  of  pregnancy  was  admitted  to  the 
municipal  hospital,  presumably  infected  by  a  criminal  abortion.  The  abdomen 
was  tympanitic,  the  lower  part  especially  being  \erj  sensitive  to  touch.  Tein- 
perature,  103.2° ;  pulse,  130.  Two  fingers  dilatation.  Within  the  canal  could  be 
felt  the  lower  extremities  of  the  fetus.  Extraction  easy ;  placenta  loosened  with 
the  finger  and  expressed.  Immediately  followLiig  this  the  patient  suffered  a 
severe  chill.  General  symptoms  of  infection  continued  to  grow  worse  until  she 
died,  five  days  later.  The  bacteriologic  examination  showed  a  staphylococcic 
infection. 

An  infection  with  general  symptoms  and  localized  inflammation 
should  be  permitted  to  run  a  spontaneous  course ;  although  a  bad 
general  condition,  accompanied  by  a  severe  hemorrhage,  may  de- 
mand more  active  treatment,  even  to  the  removal,  vaginally,  of  the 
uterus  and  the  drainage  of  the  abdominal  cavity.    The  same  opera- 


SPONTANEOUS    ABORTION 


419 


tion  would  be  indicated  if,  after  removing  from  the  uterus,  a  septic 
ovum,  a  streptoeoccemia  immediately  supervenes. 

THE  ACTIVE  TREATMENT  IN  ABORTION 

In   undertaking  any   operative   treatment   in  abortion   the  first 
thing  to  consider  is  the  state  of  the  cervix.     If  the   cervix  is 


h   g^ 


Fig.   233. — Pregnancy    at    three    months.      Note   the   increasing  vascularity    in    the   placental 
area  and  the  length  of  the  cervical  canal. 

closed,  some  procedure  becomes  necessary  in  order  to  open  it; 
and  the  nearer  such  a  procedure  comes  to  the  physiologic  act  of 
dilatation,  the  safer  jvill  it  be. 

Packing-  the  Vagina  with  Gauze. — After  painstalving  disinfec- 
tion of  both  patient  and  operator,  the  woman  is  placed  crosswise  on 
the  bed  or  on  an  operating  table,  and  a  cylindrical  speculum  is 
introduced  into  the  vagina  and  pushed  as  far  up  as  it  will  go. 


420 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


With  a  dressing  forceps  or  a  sponge-holder  the  vault  and  upper 
two-thirds  of  the  vagina  are  packed  with  iodoform  gauze,  contin- 
uing its  introduction  as  the  speculum  is  being  slowly  withdrawn. 
The  tampon  is  of  particular  value  where  the  hemorrhage  is  severe 
and  the  cervix  remains  too  tightly  closed  to  admit  the  finger.  Af- 
ter twentv-four  hours  there  is  little  danger  from  further  bleeding. 


Kig.   234. — Three   months'   ovum    with   sac   and   placenta   intact. 


the  caual  will  have  opened  and,  as  often  happens,  the  entire  ovum 
will,  upon  removing  the  tampon,  be  found  lying  in  the  vagina. 

(Fig.  234.) 

A  tampon  in  the  vagina  has  one  disadvantage,  and  that  is,  it 
acts  as  an  obstruction  to  the  discharges.    It  furnishes  an  excellent 


SPONTANEOUS    ABORTION  421 

protection  from  extrinsic  contamination,  but  it  does  not  always 
prevent  further  incubation  of  the  germs  already  present.  In  or- 
der to  minimize  this  danger  as  much  as  possible,  the  preparatory 
disinfection  of  the  parts  should  be  thorough.  At  the  end  of  twenty- 
four  hours  the  packing  should  be  removed.  Meanwhile  the  temper- 
ature must  be  taken  regularly,  and  if  it  rises  above  101°  the  tam- 
pon should  be  removed  earlier  and  a  disinfecting  douche  given. 

Dilating-  the  Cervical  Canal  with  Laminaria. — The  wood  lamin- 
aria  digitata  has  the  property  of  absorbing  moisture  and  becom- 
ing swollen.  A  pencil-like  piece  of  it  is  introduced  into  the  cervical 
canal  and  left  for  twenty-four  hours,  at  the  end  of  which  time  it 
will  have  swollen  to  the  size  of  the  finger.  In  preparing  the  tents 
the  laminaria  is  first  boiled  for  twenty  seconds,  and  then  kept  in 
absolute  alcohol  until  used.  The  outer  end  is  furnished  mth  a 
strong  thread  by  which  the  tent  can  be  readily  drawn  out  of  the 
cervix.  Inasmuch  as  it  takes  many  hours  to  effect  dilatation,  the 
applicability  of  the  device  is  limited  to  such  cases  as  require  no 
particular  haste. 

Dilating  the  Cervical  Canal  by  Means  of  Metal  Dilators. — With 
the  metal  dilator  it  is  possible  to  open  the  cervical  canal  to  the  size 
of  the  finger  in  a  relatively  short  time.  An  objection  to  the  method 
is,  that  the  cervical  tissues-  are  sometimes  injured  through  too 
rapid  dilatation.  Cautiously  and  intelligently  used,  however,  the 
metal  dilator  is  not  a  dangerous  instrument,  and  its  use  is  more 
dependable  than  either  of  the  other  two  methods  mentioned.  (For 
the  technic  of  the  procedure  see  page  83.) 

Separating  the  Ovum  from  the  Uterine  Wall 

The  finger,  after  all,  is  the  best  instrument  the  obstetrician  pos- 
sesses. After  careful  disinfection  the  left  hand  is  passed  into  the 
vagina,  the  index  or  middle  finger  continuing  on  into  the  uterine 
cavity  through  the  now  opened  cervical  canal.  Whether  the  en- 
tire hand  or  only  two  or  four  fingers  be  introduced  into  the  vagina 
depends  largely  on  the  passibility  of  the  introitus  and  the  capac- 
ity of  the  vagina.  With  one  finger  well  Avithin  the  uterus,  the  fun- 
dus is  grasped  with  the  other  hand  through  the  abdominal  wall 
and  forced  down  upon  it  from  the  outside.  The  cavity  of  the  uterus 
may  thus  be  palpated,  and  any  adhering  structure  separated  there- 


422 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


from  (Fig.  235).  AVlien  all  is  loosened  tlie  wall  feels  smooth  to  the 
finger  as  it  SAveeps  over  its  surface,  the  placental  site  alone  remaiii- 
iiig  rough  after  the  ovum  has  been  detached.  To  continue  applying 
the  fingers  to  this  area,  hoping  thereby  to  remove  this  roughness, 
would  probably  result  in  perforation  of  the  muscle  Avail.     Patho- 


Fig.    235. — Reaming   out    the    ovum   with   the    finger. 

logic  adhesions  are  rare.    The  hydatidiform  mole  is  an  example  of 
degeneration  that  can  occasionally  interfere  with  separation. 

To  separate  the  ovum  with  the  curette  is  much  more  dangerous 
than  to  do  it  with  the  finger,  and  many  instances  are  on  record 
where  perforation  has  accompanied  its  use.  For  this  reason  the 
instrument  is  of  limited  value  in  the  management  of  an  abortion. 


SPONTANEOUS   ABORTION  423 

Only  when  large  portions  of  the  ovum  can  not  be  dislodged  with 
the  finger  should  the  curette  be  resorted  to,  and  then  very  cau- 
tiously. The  patient  is  prepared  and  properly  placed  on  the  bed 
or  operating  table.  It  is  best  not  to  undertake  the  operation  with- 
out anesthesia,  though  it  can  be  done  if  the  woman  bears  pain  ex- 
ceptionally well.  The  portio  vaginalis  is  exposed  with  the  Ede- 
bohl  speculum,  and  the  anterior  lip  of  the  cervix  is  grasped  with 
bullet  forceps.  After  drawing  the  cervix  well  down,  the  length  and 
breadth  of  the  uterine  cavity  is  determined  by  soundings.  The 
canal  is  then  dilated  with  the  Leavitt  instrument  to  the  size  of  the 
index  finger,  or  until  a  broad  curette  can  be  easily  introduced.  The 
curette  is  then  cautiously  passed  into  the  uterus  as  far  as  it  will 
go,  and  withdrawn,  taking  in  a  strip  of  the  endometrium. 
This  is  repeated  a  number  of  times,  and  in  a  systematic  way.  Start- 
ing anteriorly,  long  parallel  strokes  are  made  back  and  forth,  go- 
ing a  little  farther  to  the  side  each  time,  until  the  whole  inner 
surface  from  the  fundus  to  the  cervix  has  been  gone  over.  When 
the  entire  mucous  membrane  has  thus  been  scraped  away,  the  sen- 
sation of  the  firm  underlying  musculature  can  be  felt  through  the 
curette.  The  cavity  is  then  gently  irrigated  or  effectually  sponged 
out,  and  packed  with  iodoform  gauze. 

Removing-  the  Ovum  from  the  Uterine  Cavity 

Whenever  it  can  be  done,  it  is  desirable  to  remove  the  detached 
ovum  with  the  finger ;  but  when  it  can  not  be  accomplished  in  this 
way  it  may  be  expressed  after  the  method  of  Honing.  The  uterus 
is  brought  into  a  retroverted  position,  and  the  inner  two  fingers 
Of  one  hand  applied  to  the  posterior  surface  of  the  organ,  the  other 
hand  pressing  against  the  anterior  surface  through  the  abdominal 
wall.  Simultaneously  the  inner  and  outer  hands  are  drawn  from 
above  downward,  executing  a  sort  of  milking  process  on  the  uterus. 
The  method  can  be  carried  out  successfully  even  to  the  expression 
of  the  entire  placenta,  unless  the  cervix  is  insufficiently  dilated, 
or  the  separated  part  has  remained  so  long  Avithin  the  uterus  as 
to  become  organized.  The  patient  should  be  relaxed  by  anesthesia 
before  undertaking  the  procedure;  and  if  the  abdominal  wall 
is  abnormally  thick  it  would  be  impracticable  to  undertake  it 
at  all.    The  operation  should  not  be  made  use  of  in  the  presence 


424  MANAGEMENT    OP    THE    SERIOUS    COMPLICATIONS 

of  sepsis,  as  the  squeezing  and  manipulation  is  likely  to  cause  a 
dissemination  of  the  infection  by  forcing  it  into  the  blood  and  lymph 
channels  of  the  uterus.  In  such  cases  loosened  parts  should  be 
cautiously  removed  with  the  abortion  forceps  (Fig.  236).  An  or- 
dinary sponge-holder  makes  a  fairly  good  substitute  for  this  in- 
strument, but  under  no  circumstances  should  a  sharp-pointed  in- 
strument, such  as  the  gynecologic  dressing  forceps,  be  used.  The 
risk  of  puncturing  the  uterine  wall  with  it  is  too  great.  Under  the 
direction  of  two  fingers  of  the  left  hand  the  abortion  forceps  is 
passed  into  the  uterus  to  about  half  its  length,  opened,  closed,  and 
withdrawn  (Fig.  237).  Generally  this  fetches  with  it  the  loos- 
ened ovum,  but  it  may  take  two  or  three  such  trials  to  bring  it  all 
away.  It  is  well,  however,  to  feel  within  the  cavity  with  the  fin- 
ger after  each  time  to  ascertain  if  detached  portions  are  still  re- 
maining.    AVhcn  the  embrvo  is  large,  it  is  difficult  to  remove  it 


Fig.   236. — Winter's  abortion  forceps. 


with  the  fingers,  especially  if  the  cervical  canal  is  but  partially 
dilated;  the  abortion  forceps  then  fills  the  need.  With  it  one  can 
grasp  any  part  that  presents  and,  if  the  cervix  is  well  dilated,  the 
intact  fetus  may  readily  be  brought  away. 

An  essential  part  in  the  management  of  abortion  is  to  find  out 
what  caused  it.  This  means  a  careful  inquiry  into  the  history 
of  the  case,  careful  pelvic  palpation,  serologic  tests,  and  microscopic 
and  bacteriologic  examination  of  the  aborted  ovum.  Only  when 
studied  in  this  way  can  one  expect  to  find  a  way  to  avoid  recur- 
rence. Antiluetic  treatment,  the  correction  of  malpositions,  the 
reparation  of  cervical  tears,  and  the  cure  of  an  endometritis  are 
some  of  the  remedial  measures  to  be  undertaken. 

A  simple  abortion  requires  little  after-treatment,  involution  be- 
ing practically  complete  at  the  end  of  a  week.  The  length  of  time 
the  patient  should  stay  in  bed  depends  on  the  individual.     Gener- 


SPONTxiNEOUS    ABORTION 


425 


ally  speaking,  a  week's  rest  should  be  enough.  The  next  menstrual 
period  will  occur  in  four  or  five  weeks,  and  usually  is  somewhat 
stronger  than  usual.  The  prognosis  is  not  unfavorable,  except  in 
cases  which  have  become  infected. 

Lacerations  of  a  serious  character  may  occur  with  the  dilatation, 
especially  if  undue  force  is  emploj^ed ;  but  very  much  more  serious 
are  the  injuries  that  come  with  the  cleaning  out  of  the  uterus.  The 
finger  alone  can  hardly  do  much  damage,  and  most  of  the  pene- 
trating wounds  come  from  the  use  of  metallic  instruments,  espe- 


Fig    237. — Kxlracting  the  ovnni   with  the  abortion   forceps. 

cially  the  curette  and  dressing  forceps.  A  puncture  accidentally 
made  in  an  aseptically  performed  operation,  is  not  particularly 
dangerous,  and,  except  in  the  presence  of  infection,  heals  without 
reaction  in  a  few  days.  To  perforate  a  septic  uterus,  however, 
would  be  very  serious.  Therefore,  in  dealing  with  lacerations  and 
perforations,  the  history  of  the  case  becomes  important,  since  so 
many  and  more  serious  conditions  come  into  consideration  if  the 
operation  is  unsurgically  performed.  As  compared  with  a  puer- 
peral infection,  a  septic  abortion  is  not  so  greatly  to  be  feared. 


CHAPTER  XXXI 

ASPHYXIA  OF  THE  NEWBORN 

Asphyxia  of  the  newborn  is,  in  most  instances,  a  continuation 
of  intrauterine  asphyxia.  There  are  two  grades,  distinguished  as 
asphyxia  livicla  and  asphyxia  pallida.  The  first  is  the  more  com- 
mon and  the  less  serious.  In  this  form  the  skin  of  the  wdiole  body, 
especially  of  the  face,  hands,  and  feet,  becomes  blue ;  the  heart  ac- 
tion is  slow  but  regular ;  and  respiration  is  shallow  or  stops  alto- 
gether. In  the  second  and  more  severe  grade  the  child  has  a  death- 
like pallor,  and  instead  of  the  blood  finding  its  way  to  the  surface, 
as  in  blue  asphyxia,  it  remains  for  the  most  part  in  the  internal 
organs.  There  is  a  further  difference  that  in  the  former  variety  of 
asphyxia  the  reflex  excitability  and  muscle  tone  are  preserved, 
while  in  the  latter  they  are  not.  The  asphyxia  following  an  opera- 
tive delivery  is  sometimes  so  mild  as  to  remind  one  of  narcosis; 
the  baby  breathes  regularly,  looks  good,  but  does  not  cry  out.  The 
state  is  not  necessarily  a  dangerous  one,  but  it  is  suggestive  of  a 
severe  cerebral  pressure,  which  is  dangerous. 

If  there  is  any  probabilitj'  that  the  child  may  be  born  asphyxiated, 
preparations  should  be  made  to  deal  with  it  accordingly.  A  table 
should  be  spread  with  a  sheet  overlying  a  blanket  or  something 
equally  soft;  and  plenty  of  warm  and  cold  water,  a  baby's  bath- 
tub, several  tracheal  catheters,  or  such  a  device  as  shown  in  Fig. 
238,  gauze,  towels,  etc.,  should  be  ready  at  hand.  As  soon  as  the 
head  passes  over  the  perineum,  the  baby's  mouth  and  pharynx 
should  be  mped  out  so  that  it  may  not  aspirate  with  its  first  breath 
any  of  the  mucus,  amniotic  fluid,  meconium,  and  blood  that  ac- 
company birth.  If  born  in  asphyxia,  the  child  should  be  immedi- 
ately separated  from  the  mother,  and  laid  on  the  table  where  it 
can  be  examined  satisfactorily,  its  general  condition  noted,  and 
the  degree  of  asphyxia  estimated. 

In  dealing  with  the  milder  forms  of  asphyxiation  it  may  be  nec- 
essary to  do  no  more  than  hold  the  child  up  by  the  feet  and  de- 

426 


ASPHYXIA   OF    THE    NEWBORN 


427 


liver  a  smart  slap  to  its  buttocks,  whereupon  it  will  usually  cry 
lustily.  In  other  cases  this  may  not  be  sufficient,  and  more  stim- 
ulating measures  will  have  to  be  instituted.  Tubbing  is  partic- 
ularly effective.  Placed  in  water  of  100°  F.  the 
chest  of  the  child  is  flicked  Avith  a  towel  w^rung 
out  of  ice  water.  The  first  breaths  are  generally 
rapid  and  shallow,  but  become  slow  and  deep  as 
the  treatment  goes  on.  Intermittent  traction  on 
the  tongue  will  sometimes  excite  an  inspiratory 
effort  and,  as  sho-^m  in  Fig.  239,  may  be  under- 
taken with  the  baby  in  the  tub.  The  throat  must 
l)e  kept  free  from  mucus,  and  one  of  the  easiest 
A\'ays  to  do  it  is  occasionally  to  suspend  the  child 
for  a  few  moments  by  the  heels.  Another  but 
more  complicated  method  is  to  aspirate  the  throat 
as  illustrated  in  Fig.  240. 

The  Schultze  Method  of  Resuscitation. — Per- 
haps the  best  known  method  of  resuscitating  a 
child  born  in  asphyxia  is  that  of  Schultze.  The 
operator  takes  the  bal^y  by  the  shoulders,  the 
thumbs  laid  on  the  anterior  surface  of  the  thorax, 
the  index  fingers  in  the  axillae,  and  the  other 
fingers  spread  over  the  back  of  the  child.  The 
ulnar  border  of  the  hands  act  as  a  support  to 
the  head,  thereby  preventing  it  from  falling  vio- 
lently forward  in  the  downward,  or  backward  in 
the  upward,  movement.  The  physician  stands 
with  his  feet  apart,  the  babe  held  in  the  out- 
stretched arms.  The  first  movement  of  the 
operator  is  downward  and  forward,  the  axis  of 
the  child's  body  assuming  a  perpendicular  posi- 
tion (Fig.  241a).  From  this  attitude  the  opera- 
tor straightens  his  body  to  an  erect  posture,  or, 
perhaps,  bends  a  little  backward,  the  child,  Avhich 
is  held  at  arm's  length,  SAveeping  through  the  air 
nearly  one-half  of  a  circle.  As  the  baby  reaches 
the  highest  point  in  its  excursion,  the  operator  flexes  his  elboAv, 
Avliereupon  the  infant  becomes  doubled  upon  itself,  the  extremi- 
ties falling  upon  its  face  and  chest  (Fig.  241b).    The  pressure  of 


Fig.   238.— 
Mucus  aspira- 
tor. 


428 


3IAXAGEMEXT    OP    THE    SERIOUS    COMPLICATIONS 


the  abdominal  viscera  against  the  diaphragm  causes  expiration. 
The  attitude  also  aids  in  freeing  the  air  passages  of  aspirated 
fluids,  which  may  be  further  favored  by  gently  shaking  the  baby 
a  few  times  before  proceeding  to  lower  it  again.  In  swinging  the 
child  back  to  the  first  position,  the  operator's  arms  must  be  placed 


Making  traction  on  the  baby"s  t'.nyue  as  the  child  lies  in  a  tub  of  warm  water. 
(Redrawn   from   a   photograph   by    Shears.) 


near  enough  together  to  keep  the  head  from  falling  forward  ui^on 
the  chest  and  acting  as  a  check  to  inspiration.  The  deep  descent 
of  the  diaphragm  and  the  dragging  down  of  the  liver  act  to  draw 
the  air  into  the  lungs.  When  properly  executed  an  inrushing  of 
air  to  the  trachea  can  be  heard.  These  movements  of  extension 
and  flexion  should  be  executed  eight  or  ten  times  per  minute, 


ASPHYXIA    OF    THE    NEWBORN 


429 


stopping  occasionally  to  immerse  the  baby  in  warm  water,  and  to 
make  observations  of  its  heart  action,  if  it  has  begun,  and  to 
note  the  depth  and  frequency  of  respiration.  As  soon  as  the  child 
begins  to  breathe,  stimulation  of  the  skin,  as  directed  in  the 
milder  degrees  of  asphyxia,  will  be  sufficient ;  but,  until  it  does 
begin  to  breathe,  the  heart  action  continuing,  the  swinging  move- 
ments should  be  persisted  in.     Not  until  this  treatment,  or  some 


Fig.   240. — Aspirating   the   larynx    soon    after  birth. 


other  equally  as  good  has  continued  for  half  or  three-quarters  of 
an  hour  without  results  should  one  despair  of  success. 

The  swinging  method  is  not  entirely  free  from  harm.  In  the 
hands  of  an  inexperienced  or  careless  operator,  the  violence  of  the 
movements  may  cause  rupture  of  the  liver  and  spleen  or  of  ves- 
sels, and  fracture  of  bones.  Imagine  how  serious  might  be  the  in- 
jury if,  in  throwing  the  child  upward  over  the  head,  the  operator 
should  lose  his  hold !     The  method  is  too  violent  to  use  on  a  pre- 


430 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


mature  infant';  the  structures  will  not  stand  the  strain.  Nor 
should  it  be  applied  where  there  is  cerebral  pressure  from  intra- 
cranial extravasation  of  blood,  which  so  often  is  to  be  observed  af- 
ter a  difficult  forceps  delivery.  In  such  eases  the  treatment  would 
only  tend  to  increase  the  hemorrhage.  But  one  can  not  tell  at  once 
whether  such  a  condition  is  present  or  not,  and  one  must  of  neces- 
sity do  the  best  one  can.     If  one  fears  the  asphyxia  may  be  due 


A.  B. 

Fig.   241. — Schultze    Method     of     Resuscitation.       A. — Inspiration;     B. — Expiration. 

to  pressure,  it  would  be  wise  to  make  use  of  other  and  milder 
measures. 

Various  Other  Methods  of  Resuscitation. — In  asphyxia  of  the 
second  degree  (the  pale  state)  it  does  little  good  to  irritate  the 
skin,  because  of  the  failing  excitability  of  the  reflexes.  In  these 
cases  the  resuscitative  measures  employed  are  more  in  the  nature 
of  artificial  respiration.  After  the  throat  is  wiped  out,  the  index 
finger  of  the  left  hand  is  passed  beyond  the  epiglottis  into  the  gul- 


ASPHYXIA    OF    THE    NEWBORN 


431 


let.  Along  the  palmar  surface  of  the  finger  and  directed  by  it, 
a  catheter  is  passed  into  the  trachea  (Fig.  242).  The  physician's 
mouth  can  be  applied  to  the  catheter,  and  the  mucus  withdrawn 
from  the  child's  larynx  by  suction,  but  it  is  a  little  more  agree- 
able to  do  it  some  other  way.  I  have  found  that  a  rubber  bulb 
attached  in  a  compressed  state  to  the  catheter  answers  the  purpose 
very  well.  It  can  be  applied  and  reapplied  at  will.  Before  begin- 
ning artificial  respiration  the  baby  should  be  placed  for  a  few  mo- 
ments in  the  hot  bath. 

After  aspirating  the  trachea  as  described,  air  may  be  gently  in- 


Fig.   242. — Introducing  the  tracheal   catheter. 


troduced  into  the  lungs  through  the  catheter,  which  is  al- 
ready in  place.  The  thorax  is  then  compressed  lightly,  and  the 
air  forced  out.  This  may  be  repeated  many  times ;  but  the  process 
is  not  altogether  free  from  danger,  since  if  performed  incautiously 
it  may  cause  emphysema  of  the  lungs  or  even  pneumothorax.  A 
more  satisfactory  treatment  is  found  in  the  artificial  respiration 
performed  by  the  lungmotor  or  the  pulmotor.  Either  of  these 
devices  can  be  adjusted  to  infants,  and  each  is  so  arranged  that 
oxygen,  as  well  as  air,  separately  or  mixed,  can  be  introduced. 

In  an  asphyxia  due  to  cerebral  pressure,  artificial  respiration  may 
sometimes  awaken  respiratory  and  cardiac  action,  and  for  a  time 


432 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


appear  to  be  successful,  only  to  fail  and  disappear  altogether  as 
soon  as  the  resuscitative  measures  are  discontinued. 

The  rhythmical  doubling  up  of  the  child  alternated  by  overex- 
tension ;  the  compression  of  the  thorax  with  the  hands  while  the 
child  is  held  suspended  by  the  feet;  extension  of  the  arms  above 
the  head  followed  by  compression  of  the  thorax,  as  practiced  in 
resuscitating  an  adult,  are  all  helpful,  but  less  effective  means  of 
stimulating  respiration. 

The  Lungmotor. — In  asphyxia  livida  it  does  not  much  matter 
when  the  cord  is  cut,  but  in  asphyxia  pallida  it  should  not  be  done 


Fig.    243. — Liiii,?motor    (infant's    size). 


until  the  pulsations  can  no  longer  be  felt.  The  lungmotor  (Fig.  243) 
may  be  put  into  operation  immediately  after  the  child  is  born,  with- 
out waiting  for  the  cord  to  stop  beating ;  but  the  mouth,  nose,  and 
larynx  must  first  be  thoroughly  cleared  of  mucus  and  blood  (Fig. 
244).  To  avoid  inflating  the  child's  stomach,  its  head  should  be 
drawn  backward,  and  pressure  made  over  the  epigastrium.  The  first 
movement,  that  of  drawing  the  handle  out,  sucks  air  (or  oxygen, 
if  the  physician  prefers),  into  one  of  the  two  cylinders  of  the  in- 


ASPHYXIA   OF    THE    NEWBORN 


433 


fetrument ;  the  second  movement^  pushing  the  handle  in,  forces  this 
air  or  oxygen  into  tlie  lungs  of  the  baby.  The  next  and  succeed- 
ing strokes  of  the  piston  fill  the  fresh  air  cylinder  with  air  or  oxy- 
gen, at  the  same  time  allowing  the  foul  air  in  the  child's  lungs  to 
expand  into  a  second,  or  expiration,  cylinder.  There  is  no  direct 
suction  at  any  time  upon  the  lungs,  nor  is  it  possible  to  overclis- 
tend  them,  inasmuch  as  this  second  cylinder  acts  as  a  safety  de- 
vice.    Other  means  of  resuscitation,  such  as  hot  and  cold  baths, 


Fig.   244. — Lungmotor  in   operation. 

rectal  dilatation,  stimulating  enemata,  etc.,  may  be  applied  while 
the  lungmotor  is  being  operated. 

A  resuscitated  child  requires  exceptional  care  and  nursing  for 
some  hours  afterward  lest  it  lapse  again  into  an  asphyxiated  state. 
For  a  few  days  it  should  be  kept  in  a  warm  moist  atmosphere,  pref- 
erably in  an  incubator.  Postnatal  atelectasis,  always  to  be  feared 
after  difficult  and  prolonged  resuscitation,  usually  proves  fatal 
on  the  second  or  third  day. 


CHAPTER  XXXIl 

EXTRAUTERINE  PREGNANCY 

The  subject  of  extrauterine  pregnancy  might  properly  be  con- 
sidered under  the  head  of  "Interrupted  Pregnancy"  or,  possibly, 
as  a  part  of  the  chapter  on  ' '  Hemorrhages, ' '  for  chronologically  it 
would  fall  under  either  of  these  headings.  But,  since  there  is  some 
question  as  to  whether  the  subject  should  be  discussed  at  all  in  a 
work  on  obstetrics,  I  have  thought  proper  to  place  it  at  the  end  of 
the  book  as  a  short  connecting  chapter  between  obstetrics  and 
gynecology. 

Practically,  all  that  we  know  about  the  surgery  of  ectopic  gesta- 
tion has  been  learned  within  the  last  thirty-five  years.  As  far  back 
as  the  eleventh  century  an  Arabian  physician  observed  parts  of  the 
fetus  working  their  way  through  the  abdominal  wall ;  and  in  1752 
Bohmer  assumed  to  know  so  much  about  the  subject  that  he  classi- 
fied the  various  forms  of  extrauterine  pregnancy.  But  not  until 
Lawson  Tait,  of  Birmingham,  England,  in  1883,  ventured  to  open 
the  abdomen  in  a  case  of  ruptured  tubal  pregnancy,  was  any  at- 
tempt made  to  treat  the  complication  surgically.  Since  then  it  has 
been  treated  in  almost  no  other  way. 

ETIOLOGY 

It  is  probable  that  every  pregnancy  is  extrauterine  to  begin  with, 
that  fructification  takes  place  while  the  ovum  is  on  its  way  to  the 
organ  in  which  nature  designed  it  to  grow.  Why  it  should  become 
arrested  in  transit  is  largely  conjectural.  Anatomically,  the  tube 
itself  is  not  designed  for  easy  passage ;  indeed,  it  is  to  be  wondered 
at  that,  with  its  plications,  blind  pouches,  and  kinks,  it  can  be  navi- 
gated at  all.  If  we  add  to  this  condition  some  local  disturbance, 
such  as  a  slight  constriction,  a  disturbed  epithelium,  or  pressure 
from  an  adjoining  organ  or  tumor,  we  shall  not  think  it  strange 
that  the  fertilized  ovum  occasionally  fails  to  reach  the  uterus. 

434 


EXTRAUTERINE   PREGNANCY  435 

Growing  in  its  normal  matrix,  the  dense  decidua  furnishes  am- 
ple foothold  for  the  invading  villi,  which  cease  their  proliferation 
only  when  the  placenta  becomes  fully  formed.  By  means  of  its 
trophoblast  the  ovum  buries  itself  in  the  tissues,  whether  muscular, 
connective,  or  vascular.  And  no  structure  other  than  uterine  can 
fulfill  such  demands ;  any  other  must  give  way  to  the  cytolytic 
process  of  placental  implantation. 

While  the  impregnated  ovum  may  become  arrested  along  any 
part  of  the  tract  from  the  ovary  to  the  uterus,  the  section  in  which 
it  most  frequently  finds  lodgment  is  the  ampulla  of  the  tube,  the 
most  expanded  part  of  the  duct  and  the  richest  in  vessels. 


X''' 
^ 

\ 

J    ,    • 

B'      ; 

■V-    ^, 

) 

1 

""^ 

'" 

^- 

^'-'■^' 

\ij^   ^^ 

Fig.   245. — Extrauterine    pregnancy — tubal    abortion.      The    ovum    is    being    extruded    from 
the   fimbriated  extremity   of  the  tube.      (Kelly.) 


CLINICAL  ASPECTS 

The  usual  termination  of  a  pregnancy  in  the  Fallopian  tube  is 
not  one  of  tubal  rupture,  but  one  of  tubal  abortion  (Fig.  245). 
Seventy-five  per  cent  of  the  cases  are  said  to  end  in  this  way.  The 
ovum  may,  or  may  not,  be  extruded  from  the  tube ;  even  its  detach- 
ment is  sometimes  incomplete,  pursuing  a  spontaneous  recovery, 
even  to  the  absorption  of  the  embryo. 

In  cases  in  which  rupture  occurs,  the  tube  gives  way  before  the 
third  month.  The  rupture  is  sudden  and  severe,  is  accompanied 
by  a  sharp  pain  in  the  pelvis,  and  is  followed  by  an  acute  anemia ; 


436 


MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 


the  pulse  becomes  rapid  and  feeble,  the  skin  cold,  the  countenance 
anxious.  The  immediate  cause  of  rupture  is  usually  a  strain,  a 
blow,  increased  intraabdominal  pressure^  coitus,  bimanual  exam- 
ination, or  any  undue  force. 

The  point  of  rupture  determines  somewhat  the  character  and 
seriousness  of  the  hemorrhage.  If  it  is  through  the  free  portion  of 
the  tube,  bleeding  takes  place  into  the  peritoneal  cavity  and  is  un- 
limited ;  if  between  the  folds  of  the  broad  ligament,  it  is  held  some- 
what in  check,  and  does  not  often  become  extensive  (Fig.  246).  In 
the  first  instance  the  accumulated  blood  is  sometimes  referred  to 
as  a  hematocele ;  in  the  other  as  a  hematoma.    The  only  difference, 


v.. 


Fig.   246. — Extrauterine    pregnancy — intraligamentous.       (Zweifel.) 

howevei",  is  that  the  blood  is  less  confined  in  one  than  in  the  other. 
A  hematoma  may  also  form  when  the  ovum  becomes  dislodged  but 
still  remains  within  the  ampulla  of  the  tube.  In  this  situation  it  is 
spoken  of  as  a  mole. 

The  tube  may  give  way  from  erosion  without  actually  bursting. 
A  case  of  this  kind  is  mentioned  by  Howard  Kelly.  A  young 
woman  whose  monthl}^  period  was  two  weeks  overdue  was  suddenly 
seized  with  pelvic  pain ;  she  became  blanched,  fell  in  a  faint,  and 
was  immediately  taken  to  the  hospital.  She  was  operated  on  soon 
afterward,  and  two  and  a,  half  liters  of  blood  were  removed  from 
the  abdominal  cavity ;  and  yet  all  the  bleeding  came  from  a  small 
opening  surmounting  a  bluish  red  mass  on  the  tube. 


EXTRAUTERINE   PREGNANCY  437 

How  does  ectopic  gestation  behave  if  left  to  itself? 

Sometimes  the  fetus  continues  to  live  after  bursting  from  its 
temporary  home,  and  takes  up  a  new  abode  among  the  intestines, 
omentum,  uterus,  broad  ligament,  and  bladder.  The  inner  sur- 
face of  this  extemporized  uterus  becomes  coated  with  fibrinous 
exudate,  and  the  child  goes  on  growing;  or,  possibly,  the  original 
attachment  holds,  the  omentum  and  other  viscera  backing  up  the 
weak  tube  in  a  common  federation.  In  either  case  the  placenta 
spreads  itself  over  such  structures  as  come  within  its  reach,  blood 
vessels  in  its  vicinity  enlarge,  new  ones  are  formed,  and,  Avhile 
wholly  unsuited  for  the  purpose,  the  improvised  womlj  furnishes  a 
fairly  competent  matrix  for  fetal  growth. 

In  abdominal  pregnancy  the  fetus  reaches,  after  a  time,  a  state 
of  development  when  nature  tries  to  throw  it  off.  A  spurious  labor 
forces  the  placenta  from  its  moorings,  there  is  hemorrhage,  and 
the  child  perishes;  a  conservative  peritonitis  supervenes,  the  fetus 
becomes  macerated,  the  fluids  absorb,  the  amniotic  mantle  shrinks, 
and  all  but  the  skeleton  disappears.  This  is  the  usual  process,  but 
sometimes,  instead  of  absorption,  calcium  salts  are  deposited  within 
the  sac,  and  a  lithopedion  is  formed  that  may  persist  indefinitely. 
A  case  is  reported  in  the  Britisli  Medical  Journal,  December,  1913, 
where  such  a  lithopedion  remained  in  the  mother's  abdomen  for 
forty-two  years,  during  which  time  it  caused  little  disturbance, 
and  might  never  have  been  discovered  had  it  not  been  necessary 
to  operate  for  another  trouble.  A  brief  history  of  her  case  is  as  fol- 
lows : 

At  the  age  of  twenty-five  she  became  pregnant  for  the  fourth  time.  Every- 
thing went  on  well  until  the  sixth  month,  when  growth  became  arrested,  the 
abdomen  grew  smaller,  and  all  signs  of  pregnancy  ceased;  only  a  firm  body 
remained  to  be  felt  in  the  pelvis.  Upon  the  advice  of  her  physician  nothing 
was  done.  Subsequently  she  bore  four  children,  the  mass  rising  with  each 
pregnancy,  and  returning  again  to  the  pelvis  after  deliveiy.  The  lithopedion, 
when  removed,  was  surrounded  with  cartilaginous  bands.  The  head  measured 
eight  and  three-fourths  inches  in  circumference. 

Another  and  not  unusual  way  for  the  dead  fetus  to  get  out  of 
the  abdomen  is  by  means  of  infection.  Pus  germs  gain  access  to 
it  through  the  blood  stream  or  through  the  intestinal  wall,  and 
carry  it  away  by  purulent  disintegration.  Exit  may  be  through 
the  bladder,  the  rectum,  or  the  abdominal  wall. 

Some  very  strange  things  can  happen  in  connection  with  extra- 


438  MANAGEMENT    OF    THE    SERIOUS    COMPLICATIONS 

uterine  pregnancy,  one  or  two  of  whicli  may  be  mentioned.  For  ex- 
ample, a  case  has  been  reported  in  which  extrauterine  pregnancy 
occurred  after  removal  of  the  uterus,  the  spermatozoa  finding  their 
way  through  a  cervical  fistula  and  germinating  the  ovum  within 
the  tube.  Dr.  H.  P.  Wilson,  of  Baltimore,  in  1880,  after  deliver- 
ing a  woman  easily  and  naturally  of  a  living  child  discovered  an- 
other fetus  within  the  abdominal  cavity.  Being  about  twenty- 
three  days  short  of  ievm,  is  was  decided  not  to  operate  till  later. 
The  following  month  the  abdomen  was  opened,  and  a  living 
child  weighing  eight  pounds  was  delivered. 

DIAGNOSIS 

At  first  there  are  amenoi'rhea  and  other  signs  of  pregancy,  such 
as  nausea,  changes  in  the  breasts,  etc.  Accompanying  these  symp- 
toms, but  appearing  at  irregular  intervals,  the  patient  suffers  at- 
tacks of  pain  so  severe  that  sometimes  it  amounts  to  shock,  and  she 
is  found  in  collapse.  Although  there  is  an  interruption  of  the 
menses  they  are  likely  to  recur,  sooner  or  later,  accompanied  by  the 
discharge  of  a  decidual  cast  (Fig.  247),  large,  thick,  and  well 
organized,  the  stroma  cells  of  which  have  dense  well-defined 
nuclei.  The  dysmenorrheal  cast  differs  from  it  in  that  the  men- 
strual cast  is  heavily  infiltrated  with  leucocytes,  and  is  much 
smaller  in  size. 

While  the  decidual  cast  is  of  much  diagnostic  value,  it  is  a  symp- 
tom of  extrauterine  pregnancy  that  is  sometimes  slow  to  make  its 
appearance.  In  fact,  it  may  not  be  expelled  until  after  the  neces- 
sary surgical  procedures  have  been  carried  out,  or,  possibly,  not  at 
all.  Surely,  its  appearance  should  not  be  awaited  in  arriving  at  a 
conclusion. 

Another  condition  that  may  be  confused  with  a  sudden  rupture 
of  the  tube  in  ectopic  pregnancy,  is  an  ovarian  cyst  with  a  twisted 
pedicle.  This  condition  may  be  so  acute  as  to  become  very  mis- 
leading, especially  if  it  is  accompanied  by  a  hemorrhagic  discharge. 

Every  abdominal  surgeon  of  much  experience  has  mistaken  an  in- 
flamed tube  for  one  of  tubal  pregnancy,  and  operated.  It  is  also 
true  that  he  has  operated  for  pyosalpinx,  and  found  extrauterine 
pregnancy.  This  fact  shovrs  how  nearly  alike  in  their  symptoms 
the  two  affections  may  be. 


EXTRAUTERINE   PREGNANCY 


439 


But  the  mistake  most  commonly  made  is  to  confound  extra- 
uterine with  intrauterine  pregnancy,  the  physician  imagining  he 
has  only  an  incomplete  abortion  to  deal  with.  The  character  of  the 
pain  alone  should  be  pathognomonic.  In  intrauterine  pregnancy 
it  begins  mildly,  is  regular,  and  of  increasing  severity-;  in  extra- 
uterine pregnancy  it  is  sudden  in  its  onset,  variable  in  severity, 
and  spasmodic. 

Extrauterine  pregnancy  is  also  mistaken  for  appendicitis,  par- 
ticularly if  the  diagnosis  is  made  on  the  physical  findings  alone. 


Fig.  247. — Decidual    cast. 

But,  if,  in  addition  to  the  signs  of  pregnancy,  the  woman  is  seized 
with  sudden  and  excruciating  pain  in  the  pelvis  and  is  pale  and 
faint,  the  diagnosis  of  a  ruptured  tube  is  quite  definite.  Palpation 
reveals  very  little  other  than  tenderness.  Fluid  blood  in  the 
abdomen  is  not  easily  determined,  and  it  requires  a  day  or  more 
for  it  to  become  clotted. 


TREATMENT 

The  only  recommended  treatment  in  extrauterine  pregnancy  is 
surgical,  and  this  treatment  should  be  used  whether  the  tube  has 


440 


MANAGEMENT    OP"    THE    SERIOUS    COMPLICATIONS 


ruptured  or  not ;  and  the  earlier  the  surgical  interference,  the 
better  Avill  be  the  prognosis.  Such  statements  are  perhaps  some- 
what dogmatic  since  some  gynecologists  hold  that  a  reasonable  de- 
lay after  rupture  may,  under  certain  circumstances,  be  an  advan- 
tage.   But  most  surgeons  agree  that  no  matter  what  the  patient's 


Fig.   248. — E>;trauterine  pregnancy;   the  tube  on  the  ruptured  side  clamped  ready   for   liga- 
tion  and   resection. 


condition  is,  ectopic  gestation  is  a  menace,  and  should  be  obliter- 
ated at  once. 

In  the  presence  of  hemorrhage  one  needs  to  work  rapidly.  No 
time  should  be  lost  in  more  elaborate  preparation  than  to  paint 
the  abdomen  with  iodine.  The  transverse  or  median  incision 
may  be  employed.  As  soon  as  the  peritoneal  cavity  is  opened,  free 
blood  wells  from  the  wound.     Without  stopping  to  inspect  or  ex- 


EXTRAUTERINE   PREGNANCY  441 

plore,  the  fingers  or,  possibly,  the  whole  hand  is  introduced,  and 
both  tubes  palpated.  Upon  locating  the  lesion,  the  tube  on  that 
side  is  clamped  close  to  the  uterus.  Then,  in  more  deliberate  meas- 
ure, one  proceeds  to  clear  away  the  obscuring  blood,  and  to  resect 
the  ruptured  duct  (Fig.  248). 

Where  a  hematocele  has  formed  some  surgeons  say  that  it 
should  be  removed;  others,  that  it  should  be  opened  into  from 
below;  still  others,  that  it  should  be  left  alone. 

The  last  are  probably  nearest  right  since  the  chief  danger,  that 
of  hemorrhage,  is  then  over,  and  absorption  goes  on  rapidly. 

Another  mooted  question  is,  "Shall  the  unaffected  tube  be  re- 
moved?" To  wdiich  most  obstetricians  Avould  answer,  "Yes." 
KnoAving  how  apt  pregnancy  is  to  follow  in  the  other  tube,  it  seems 
rational  to  excise  it.  At  least  the  danger  of  leaving  it  should  be  dis- 
cussed with  the  parties  concerned. 

Extrauterine  pregnancy  furnishes  a  good  illustration  of  the  dif- 
ference between  a  physiologic  and  a  pathologic  process.  Physiol- 
ogy implies  forethought ;  pathology,  afterthought.  One  is  the  other 
working  to  advantage  or  disadvantage,  as  the  case  may  be.  While 
both  seek  to  accomplish  the  same  end,  the  one  follows  after  a  defi- 
nite formula,  and  is  successful ;  the  other  struggles  on  blindh'. 
and  accomplishes  its  purpose,  but  imperfectly. 


INDEX 


A 

Abdomen,     abnormal     swellings     and 
tumors  of,  in  child,  239 
bimanual  compression  of,  in  mother, 

172,  205,  247 
l^eudiiloiis,   395 
Abdominal  cavity,  adhesions  in,  250 
escape  of  child  into,  in  abdominal 
pregnancy,  437 
in   rupture   of   the   uterus,    313 
in  cesarean   section,  255 
cesarean  section    (see  Cesarean  sec- 
tion) 
hysterectomy,    for   carcinoma,   407 
for  myoma,   406 
in   cesarean   section,   251,   252 
in  rupture  of  the  uterus,  315 
incisions   in    cesarean    section,    250, 

258,  264,  267,  272 
pregnancy,  437 
pressure,  insufficiency  of,   292 
to   fix   the  hesd   for   perforation, 
220,  225 
walls,  attenuation  of,  in  pregnancy, 
250 
suturing    of,     after    laparotomy, 
255,  257,  260 
Ablatio  placentae,  340 
Abortion,  416 

active  treatment  of,  419 
classification,  416 
complete,  417 
criminal,  418 
curettage  in,  422 
ourettement  in,  423 
diagnosis,  416 
dilatation  of  cervix  in,  421 
expectant  treatment,  417,  418 
forceps,  424 

Honing 's  manipulation  in,  423 
hysterectomy  in,  418 
incomplete,  417 

indications  for  induction  of,  49 
inevitable,  417 
infection  in,  418 
injuries  accompanying,  425 
iodoform  gauze  tampon,  use  of,  in, 
419 


Abortion — Cont  'd 
prognosis  in,  425 
removing  the  ovum,  423 
with  the  curette,  422 
with  the  finger,  421 
septic,  418 

compared   with   puerperal   sepsis, 

425 
treatment,  418 
spontaneous,  416 
threatened,  416 
tubal,  435 
Absolute  pelvic  contraction,   378,  386 
Absorption  of  the  fetus  in  extrauter- 
ine pregnancy,  437 
of   the   ovum   in   extrauterine   preg- 
nancy,   435 
Acetonuria  in  diabetes,  67 
Accidents,  perforation  of  the  sacrum, 
226 
slipping  of  the  cranioclast,  226 
slipping  of  the  forceps,  199,  202 
Accouchement  force,   276 
Acute  hydramnion,  55 

as  an  indication  foi-  interrupting 
pregnancy,    55 
Acute    infections    during    pregnancy, 

38 
Adherent  placenta,  292 
Adhesions    in    abdominal    cavity,    272 
making   reduction    of   the   incarcer- 
ated sravid  uterus  impos- 
sible, "58 
After-birth    (see  Placenta) 
After-birth   period    (see    Tliird    stage 

of  labor) 
After-care,  following  abortion,  424 
following  eesaiean  section,  268 
following    the    pelvic-enlarging    op- 
erations, 104,  106 
following  resuscitation,  433 
Afjfer-coming  head,   delivery   of,   150, 
164,  169,  224,  245 
perforation   of,  218 
Air   emboli,    297 

Albuminuria  during  pregnancy,  65 
Albuminuric  retinitis,   66 
Amenorrhea     in     extrauterine     preg- 
nancy, 438 


443 


444 


INDEX 


Amnion,    preservation    through    col- 
peurysis,  363,  393 
puncturing  of,  74 

after  external  version,  119 

as  a  joain-produeing  measure,  393 

in   combined  version,    132 

in  contracted  pelves,  392 

in  eclampsia,  399 

in  face  piresentation,  366 

in  hydramnion,  71 

in  placenta  previa,  343 

in    premature    separation    of    the 

placenta,  350 
in  transverse  position,  359 
in  twins,  353 

possibilitv  of  infection  follov^"iug, 
393 
Amniotic  fluid,  decomposition  of,  353 
increased  in  twins,  353 
slow  discharge  of,  375,  393 
Ampulla  of  oviduct,  435 
Anatomy  of  the  symphysis  pubis,  93 
Anemia,     acute,     autotransfusion    in, 
305 
death   from,    following    abortion, 

417 
hypodermoclysis  in,  304 
infusion  in,  297,  304 
proctoclysis  in,  305 
prognosis,  307 
symi)toms,  293 

treatment  of,  297,  302,   347,  349 
pernicious,  67 
Anencephalus,  410 
Anesthesia,   34 
chloroform,  34 
ether,  35 

in  ''supporting"  the  perineum,  331 
in  reducing  the  incarcerated  gravid 

uterus,  57 
spinal,  35 

"twilight  sleep,"  35 
Ankylosis  of   sacroiliac  joint,  203 
Anomalies  and  malformations,  410 

of  the  soft  parts,  244 
Anterior      commissure,      injuries      of, 

202 
Anterior    parietal    bone,    engagement 

of,  390 
Apnea  of  the  newborn,  275 
Apparently  dead   (see  Asjjhyxia) 
Applicaljility  of  vaginal  cesarean  sec- 
tion, 278 
Application  of  forceps   (see  Forceps) 
Aristol,  use  of,  336 
Arm   extraction,   161 


Arm  extraction — Cont  'd 

in  breech  positions,  161 

in  high  extension,  161 

when     the     child's     abdomen     is 

turned  anteriorly,  164 
when    rotated    behind    the    neck, 
162 
Arteries,  dorsal  of  clitoris,  202 
obturator,  94 
uterine,  166,  314 
Artificial   aeration   of   the   lungs,   401 
dilatation  of  the  cervix,  77 
in  abortion,  421 
in  eclampsia,  399 
in    perforation    and    cranioclasis, 

■     210 
in    premature    separation    of    the 
placenta,  350 
interruption  of  pregnancy,  49 
indications,     conditions     due     to 
pregnancy,  49-60 
conditions    due    to    concurrent 
affections,  60-67. 
methods  of  inducing  abortion,  67 
methods    of    inducing    premature 

birth,  72 
prognosis,  76 
rest  in  inertia,  45 
Asepsis   as   applied  to   obstetrics,   21, 

246 
Asphyxia,  anticipatory  measures,  426 
as    an    indication    for    the    use    of 

forceps,  171 
as    an    indication    for    vaginal    ce- 
sarean section,  278 
cerelu-al  pressure  in,  43,0 
from    pressure    of    forceps    on    the 

cord,  204 
in  deli\'ery  by  cesarean  section,  275 
intrauterine,  109 
livid  form,  426 
of  the  newborn,  426 
pallid  form,  426 
signs  of,  during  labor,  171 
treatment,  426 

artificial  respiration,  430 
aspiration    of    the    throat,     427, 

431 
intermittent      traction      on      tlie 

tongue,  427 
lung  motor,  use  of,  432 
Schultze's    swinging    movements, 

427 
skin   irritation,  427,   429,  430 
tubbing,  427 
Assistance,  36 

in  cesarean  section,  247 


INDEX 


445 


Atelectasis,  postnatal,  433 
Atlas,  separation  from  occipital  bone 
in  perforating  the   after- 
coming  head,  219 
Atony   of   the   uterus,   after   cesarean 
section,   274 
after  birth  of  the  placenta,   292 
before  birth  of  the  placenta,  289 
following  the  birth  of  twins,  355 
management  of,  292 
Atresia    of    the    vagina    and    cervix, 

244 
Atypical   forms   of    embryotomy,   238 
Attitude,  anomalies  of,  108 

normal,    108 
Auscultation      of      the      fetal      heart 

sounds,  182,  394 
Autotransfusion,  305 
Axis-traction   bar,    171 
forceps,  196 

B 

Balloon,       (see      MetreurAmter,      Col- 

peurynter,        Hydrostatic 

bag. 

Bandaging    of    the    abdomen,    after 

external  version,  119 

after  rupture  of  the  uterus,  314 

Baudl,    ring    of,    228,    292,    293,    311, 

359 
Bartholinitis,    409 

Baths,  hot,  in  asphyxia  of  the  new- 
born, 427 
in    eclampsia,   400 
Bandeloeque  diameter,  384 

manipulation   of,   108 
Behavior  of  extrauterine  pregnanev 

if  left  to  itself,  437 
Berlin  clinics,  41 
Billroth 's  mixture,  399 
Bimanual  compression  of  the  uterus, 
172 
in   cesarean   section,   251 
in  Kristeller's  expression,  206 
to   fix   the   head   in   perforation, 
214 
examination     as     the     immediate 
cause  of  ruj^ture  in  extra- 
uterine pregnancy,  436 
Birth  canal,  enlargement  of,  93 
in   cesarean  section,  246 
complicated  by  tumors,  402 
mechanism,   in   the   generally   con- 
tracted pelvis,  390 
in  flat  pelves,  390 
in   kyphotic   pelves,   391 


Eirth,   mechanism — Cont  'd 

in    obliquely    contracted   pelves, 

391 
in  the  occipitoposterior  position, 

365,  396 
in  transverse  positions,  358 
Biting  the  tongue  in  eclampsia,  400 
Bladder,  imbrication  of,  in  cesarean 
section,   266 
injuries   of,   in   lacerations   of   the 
vagina,  320,  321 
iu    pubiotomy    and    symphysiot- 
omy, 105 
in  rupture  of  the  uterus,  312 
Bleeding,  before  birth  of  the  child, 
340,  347,  348 
following    birth    of    the    placenta, 

347 
from  the  cord,  354 
in  abortion,  417 
in  lacerations,  202,  318 
in  the  early  luonths  of  pregnanev, 

416 
in  the  pelvic-enlarging  operations, 

96,  104 
in   the   placental    period,    289,    292, 

294,  297 
to  death,  348 
Blindness  in  nephritis,  66 
Blood,  diseases  in  pregnancy,  67 
Blue    baby     (see     Asphyxia     livida) 
Blunt  hook,  156 

use      of,     in      delivering     anence- 
phalic  fetus,  410 
Body  heat,  maintenance  of,  302 
Bohmer,  434 
Bone  forceps,  224 
Bojie,  fracture  of  extremities,  167 

fracture  of  the  skull,  168 
Bossi  dilator,  83,  87 
Bougie  for  induction   of  labor,  73 
Braun  balloon,  78 
cranioclast,  211 
decapitation  hook,  230 
Braxton-Hicks  version,   130 
Breech-birth,  141 
course  of,  141 

delivery  of  the  after-coming  head, 
149,  164 
Prague  method,  165 
Veit-Smellie  method,  164 
Wigand-Martin-Winkel       method, 
164 
frequency  of,  in  twins,  357 
prognosis,  169 
use  of  forceps  in,  200 


446 


INDEX 


Breech   extraction,   1-J-l    (see   also  Ex- 
traction) 
with  finger,  154 
with  hook,   154,   156 
with  sling,  155 
hooks: 

Kiistner's,  157 
Smellie's,  156 
position  and  prolapse  of  the  cord. 
Ill 
Broese,  manipulation   of,  in  version, 

135 
Brow  presentation,  193,  367 
above  the  inlet,  367 
arrested  in  descent,  367 
cesarean  section  in,  367 
correction  of,  367 
conversion  into  face,  367 
conversion  into  vertex,  367 
forceps  in,  193,  367 
Bruises  and  contusions  of  the  child 

in   forceps   delivery,   204 
Bumm,  21 

pubiotomy  needle,   97 
pubiotomy  operation,  101 
Bunge's    sling   carrier,   155 

C 

Calcium  salts,  deposit  of,  in  abdom- 
inal  pregnancy,   437 
Camphorated   oil,  401 
Cannula   for  washing   out   the  brain 

substance,  217 
Caput  succedaneum,  396 
Carbohydrates,    withholding    of,    in 

contracted  j^elves,  395 
Carcinoma,  as  an  indication  for  rad- 
ical  cesarean    section,    269 
of   the   rectum,   409 
of  the  uterus^  407 
of  the  vagina,  244 
Carrying-needle    (see  Pubiotomy  nee- 
dle) 
Castor  oil,  269 
Catgut,  preparation  of,  33 
Catheter,  self -retaining,  321 
Catheterization  of  the  bladder,  after 
pubiotomy  and  symphysi- 
otomy, 104 
before    attempting   to   reduce   in- 
carcerated    gravid    uterus, 
57 
in  eclampsia,  401 
Catheterization   of  the   trachea,  431 
Cauterization    in    carcinoma    of    the 
uterus,  407 
in  condylomatous  growths,  409 


Central  rupture  of  the  perineum,  336 
Cephalhematoma,   166 
Cephalotribe,  224 
Cerebl-al  pressure,  426,  430 
Cervical     cesarean    section     (see    Ce- 
sarean section) 
dilatation     (see    Dilatation    of    the 
cervix) 
in  breech-birth,  141 
in  perforation   and  cranioclasis, 
210 
incisions,   166,  175 
lacerations  (see  below) 
scars,  410 
Cervix,  lacerations  of,  202,  316 
etiology  of,  316 
hemorrhage  in,  316 
in  placenta  previa,  316 
in  rupture  of  the  uterus,  138 
prognosis  in,  318 
suturing  of,  317 
tampon,  use  of,  in,  317 
Cesarean  section,  abdominal,  242 

■abdominal   adhesions   in,   272 
after-care,   268 
classic  section,  250 
competing  operations,  95 
conservative   section,   250-268 
advantages     and     disadvair- 
tages  of,  268 
delivery  of  the  child,  264 
diflSculties    of,   272 
drainage,  272 

extraperitoneal  section,  266 
historic   sketch,   242 
indications     and      conditions, 

243 
instruments  used,  243 
in    carcinoma,    of   rectum,    409 

of  the  uterus,  407 
in  eclampsia,  244,  398 
in  the  home,  248 
in   the  hospital,   247 
in  myoma,  406 
in  osteomalacia,  243 
in   ovarian   tumors,  402 
in  placenta  previa,  342 
in   prolapse  of  the  cord,  374 
in     sudden      death      of      the 

mother,  245 
on  the  dead  and  dying,  276 
Porro  's   operation,   242 
postoperative  atony,  284 
prognosis  and  statistics,  274 
preliminary   conditions,   246 
preliminary  preparations,  247 
in  the  home,  248 
in  the  hospital,  247 


INDEX 


447 


Cesarean  section,  Abdominal — Cont  'd 
radical   section,   269 
relative   indications,  387 
Saenger's  operation,  250 
suprasymphyseal  hysterotomy, 

258 
suturing  the  uterus,  254 
technic,  252 

the  brow  presenting,  267 
the  face  presenting,  366 
total     extirpation     of    uterus, 

271 
transverse  incision  of  fundus, 

250 
transperitoneal  section,  263 
when  the  placenta  overlies  the 
incision,  273 
radical,  269 

extraperitoneal    treatment    of 

the  pedicle,  269 
indications  for,  269 
Porro,  242 

preliminary  preparations,  269 
prognosis  and  statistics,  274 
retroperitoneal    treatment    of 

the  pedicle,  269 
total     extirpation     of    uterus, 
271 
.    vaginal,  175,  278 
applicability,   278 
craniotomy  in,   283 
instruments  used,  279 
indications,  278 
in  eclampsia,  245 
laceration   accompanying,   282 
preliminary      conditions,     279, 

388 
preliminary  preparations,   279 
prognosis   and  statistics,   285 
suturing,    285 
technic',  280 

.  use  of  forceps  in,  283 
version  in,  283 
Champetier     de     Ribes     hydrostatic 

bag,  78 
Changes  in  prolonged  labor,  172 
Child 's    bodv,    acting    as    a    dilator, 
77 
acting  as  a  tampon,  343 
head,  molding  of,  390 

overlapping   of  bones,   389 
size  and  plasticity  of,  389 
parts,  distinctly  felt  in  rupture  of 
the  uterus,  310 
Chills,  significance  of,  39 


Chlorofomi    anesthesia,    34    {see    also 
Narcosis) 
in  breech  extraction,  142 
in  eclampsia,  399 
in  the  expulsive  stage,  331 
Chondrcdystrophia   fetalis,  413 
Chorea  during  pregnancy,  66 
Chorioepithelioma    {see   Hydatidiform 

mole) 
Classic    cesarean   section,   250 
Classification  of  abortions,  416 

of  pelvic  contractions,  376 
Clavicle,  fracture  of,  167 

resection  of,  410 
Claw    forceps,    use    of,    in    cesarean 

•section,  252 
Cleavage   and  expulsion   of   the  pla- 
centa, 287 
Cleidotomy,  410 

Clitoris,   contiguous   structures   of,   94 
Closed   and   undilated   cervix   as   an 
indication     for     cesarean 
section,  244 
Clyster  before  labor,  23 

following  abdominal  section,  269 
Coaptation    of    muscle    wall    in    cesa- 
rean section,  254 
Codeine  in  abortion,  417 
Coincident   affections   of   pregnancy, 

37 
Coitus    as    the    immediate    cause    of 
rupture     in     extrauterine 
pregnancy,  436 
Colpeurynter,  use  of,  as  a  tampon  in 
placenta  previa,  91 
in   contracted  pelves,  395 
in    dilating    the    introitus,    138, 

332 
in  inertia,  44 

in  prolapse  of  the  cord,  369 
in     reducing     the     incarcerated 

gravid  uterus,  57 
in  reducing  the  inverted  uterus, 

299 
to  incite  uterine  activity,  91 
to  prevent  the  amniotic  sac  from 
rupturing,  91 
Colpeurysis,   91 

indications  for,   91 
technic  of,  91 
Colpohysterotomy    {see    Cesarean    sec- 
tion, vaginal) 
Colpotomy,  403 
Combined  version,  130 
difficulties  of,  134 
indications    for,    131 
in  placenta  previa,  345 


448 


INDEX 


Combiued  version — Cout  'd 
prognosis,  137 
teclmic,  132 
Compensatory  disturbances  of  heart 
during  pregnaucr,   61,   62 
Complete  abortion,  417 
Comj)lete  laceration  of  tlie  perineum. 

326 
Comijlete  rupture  of  the  uterus,  312 
Complications  in  birth  of  twins,  355 
Compound  presentation,  113 
Compression,     of     the     abdomen     in 
breech-births,   205 
of  the  cord,  114 

of  the  child's  head  with  the  for- 
ceps, 181,  196 
Conditions   making  reduction   of  in- 
■   carcerated    gravid    uterus 
impossible,  58 
Conditions    making   perforation    and 
crauioelasis         necessary, 
209 
Conduj)licato  corpore,  361 
Condylomata  of  the  vulva,  409 

as  an  etiologic  factor  in  lacera- 
tions of  the  perineum,  325 
Conservative    operations    (cesarean) 
compared,  268 
peritonitis    in    extrauterine    preg- 
nancy, 437 
cesarean  section   {see  Cesarean  sec- 
tion) 
Constriction  with  the  Momburg  tube, 

300 
Contracted    pelves,    378     {see    Pelvis, 

contractions  of) 
Contraction    of    the    cervix    in    the 

third  stage  of  labor,  297 
Contraction  ring  of  Bandl,  228 
in  breech-births,   111 
in  contracted  pelves,  394 
in  cross-births.  111,  228 
in   manual   delivery   of  the  pla- 
centa, 294 
in    threatened    rupture     of     the 

uterus,  311 
in  version,  135 
Contraindications    to    conversion    of 
face   and  brow   positions, 
109 
to  pubiotomv  and  svmphvsiotomv, 

95  ' 
to  use  of  vaginal  tampon,  347 
to  version,  40,  121,  229 
Conversion  of  deflections   {see  correc- 
tion of  faulty  attitudes) 
Corporeal  hysterotomy,  250 


Correction  of  faulty  attitudes,  lOS 
Coxalgic   pelvis,  377 
Cranioclasis,  applied  to  the  trunk  of 
the   child,   236 

difficulties  of,  225 

indications  for,  209 

in  macerated  fetuses,  225 

of  the  after-coming  head,  224,  225 

of  the  perforated  head,  220 

prognosis,  226 

technie,  220 

use  of  bone  forceps  in,  224 

use    of    tribladed    cranioelast,    224 
Cranioelast,  Boer 's  bone  forceps,  211 

Braun's,  211 

]\Iesnard-Stein  bone   forceps,   211 
Craniotomy  {see  Perforation) 
Crede 

dictum  of,  297 

exf)ression  of  placenta,   290 
Criminal  abortion,  418 
Cross-births,    favoring    displacement 
of  extremities,  111 

necessity  of  version  in,  129 
Curettement,  422 
Cyanosis,  400 

Cystic    degeneration   of   the   chorion 
{see    Hydatidiform    mole) 
Cvstoseopv    in    lacerations     of     the 
■  bladder,   321 

D 

Dangers  to  the  child,  45,  138 

from   disturbed   placental   circu- 
lation, 45,  46,  354 
from  Kristeller's  expression,  207 
to  the  mother,  37 
from  eclampsia,  40 
from  general  exhaustion,  41 
from  impeded  birth,  229,  394 
from  internal  affections,  38 
from  making  an  incomplete  rup- 
ture   of    the    uterus    com- 
plete, 312,  314 
from  puerperal  fever,  38,  39 
from  sepsis,  226,  299 
from  too  rapid  delivery  of  sec- 
ond twin,  355 
from  weakness  and  inertia,  42 
Dead  and  dving,  cesarean  section  on, 

276" 
Death,  habitual  of  the  fetus,  55 
from   pressure    of    forceps   on   the 

cord,   204 
of  the  mother  from  impeded  birth, 
229 


INDEX 


449 


Decapitation,  22S 

after   the   head   is    delivered,   230, 

236 
before   the  head  is   delivered,  231 
hook,  230 

instruments  used,  230 
preliminary  conditions,  230 
scissors,  230 

with  decapitation  hook,  232 
with  the  scissors,  232 
technie,  231 
Decapitated  head,  extraction  of,  230 
Decapsulation     of     the    kidneys     in 

eclampsia,  401 
Decidua   in   extrauterine   pregnancy, 

435 
Decidual   cast   in   extrauterine   preg- 
nancy, 438 
Decidual  degeneration,  348 
Decomposition  of  the   amniotic  tiuid, 

39,  172 
Deflexed  positions  of  the  head,  365 
of  the  brow,  367 
of  the  face,  366 
of  the  occiput,  365 
Degeneration,   galvanic   reaction   of, 

168 
De  Lee,  376 

Delivery  in  carcinoma  of  the  uterus, 
407 
in  cesarean  section,  252,  260,  264 
in  rupture   of  the  uterus,  313 
of  the   after-coming  head,   164 
of  the  decapitated  head,  230 
of   the   shoulders,   184 
of  twins,  356 
'Delivery  bed,  25,  26,  27 
Depression  of  the  parietal  bone,  204 

spoon-shaped  of  the  head,  168 
Dermatol,  deodorizing  powder,  407 
Detachment  of  the  ovum  in  extrau- 
terine   pregnancy,   435 
Diabetes  mellitus  in  pregnancy,  67 
as  an  indication  for  interrupting 
pregnancy,  67 
Diagnosis  of  cervical  tears,  316 
of   epiphyseal  separation,   167 
of  extrauterine  pregnancy,  438 
of  fractures,  167 
of  hydatidiform  mole,  52 
of  hydrocephalus,  413 
of  incarceration  of  gravid  uterus, 

56 
of  injuries  of  vulva  and  perineum. 

327 
of  pressure  injuries,  323 


Diagnosis — Cont  'd 

of  spontaneous  abortion,  416 
of   uterine    rupture,    312 
of  vaginal  tears,  321 
Diaphoresis  in  eclampsia,  400 
Diet,  Prochownik's,  395 
.  Differential    diagnosis   in    extrauter- 
ine pregnancy,  438 
Difficulties   in   cesarean   section,   272 
in    delivering    shoulders    in    anen- 
cephalic  fetus,  410 
Diffuse     peritonitis    following    cesa- 
rean section,  275 
Digitalin  in  heart  failure,   62 
Dilatation  of  the  cervix,  69,  70,  71,^ 
141 
by  cervical  incisions,  89 
by    continuous    traction    on    the 

the  child's  body,  77 
by    forcible    extraction    of    the 

child,    89 
bv  use  of  metal  dilators,  74,  83, 

84,  85,  86,  87,  421 
with  Hegar's  sounds,  71 
with  gauze  tampon,  67 
with   the   hand,   82 
with    the    metreurynter,    78,    79, 

80,  81 
with  tents,  69,  420 
Dilators,  Bossi's,  83 
Hegar's,  71 
Leavitt's,  74 
Discharge     of     bad-smelling     liquor 
amnii,  39 
of  feces  into  vagina,  321 
of  meconium,  46 
of  urine  into  vagina,  321 
Disinfection,  21 
of  genitals,  23 
of  hands,  22 
of  instruments,  32 
of  operator,  22 
of  patient,  23 
of  rubber  gloves,  22 
Disintegration    of   fetus   in    abdomi- 
nal pregnancy,  438 
Dislocation  of  the  vertebra^,  168 
Dismembering  operations  (see  Embry- 
otomy) 
Displacement    of   the   gravid  uterus, 

55 
Disturbances    of    placental    circula- 
lation,    45 
of  the  pulse,  39 

of  the  third  stage  of  labor,  292 
of  placental  cleavaae,  292 
of  placental  expulsion,  292,  293 


450 


INDEX 


Diuresis  in  eclampsia,  401 
Doderlein's  pubiotomy  needle,  97 

operation,  cesarean  section,  262 
Dorsal   artery  of  the   clitoris,  202 

position   in   delivery,   331 
Double  formations,  of  the  child,  414 
of  the  uterus,  410 
of  the  vagina,  410 
monsters,  414 
Douches    in   the    treatment    of   local 

fetor,  407 
Douglas,  culdesac  of,  2S3 
Dressings,  in  cesarean  section,  260 
of  perineum  after  suturing,  336 
preparation    and    sterilization    of, 
33 
Diihrssen,  285 

cervical  incisions  of,  87 
Duncan's   mode   of   placental    cleav- 
age, 287 
Djaiamics  of  forceps  delivery,  202 

E 

Ecchvmoses    from    forceps    delivery, 

204 
Eclampsia,  40,  398 

abdominal  cesarean  section  in,  244 
biting  the  tongue  in,  400 
dilating   the   cervix  in,  by   means 
of  incisions,  398 
by  means  of  a  weighted  metre- 
urynter, 399 
with  the  child's  body,  399 
with  instruments,  399 
diuretics  and  diaphoretics  in,  401 
forceps  delivery  in,  398 
management     of,      during      early 
months  of  pregnancy,  399 
during  labor,  398 
mortality,  401 
most  effective   therapy,  399 
loerforation     and    cranioclasis     in, 

398 
promotion    of    metabolism    in,    400 
prophylaxis,  401 
statistics,  401 

Stroganoff's   treatment,  399 
vaginal  cesarean  section  in,  398 
version  and  extraction  in,  398 
Ectopic    gestation    {see    Extrauterine 

pregnancy) 
Edebohl's  speculum,  74,  87 
Edema  of  the  vulva,  408 

as    an    etiologic   factor   in   lacera- 
tions, 325,  408 
Elastic  ligature,  use  of,  in  the  Porro 
operation,  271 


Emboli  of  air,  in  manual  delivery  of 
the  placenta,  297 
in    symphysiotomy    and    pubiot- 
omy, 106 
Embryotomy,  228 

atypical  conditions  and  procedures, 

238 
cleidotomy,  239 
decapitation,  228 
difficulties,  236,  239 
exenteration,  238 
in  birth  of  twins,  357 
in  transverse  positions,  359 
indications,  228 
instruments  used,   230 
perforation  and  cranioclasis,  208 
extraction  of  the  perforated  head, 

220 
indications,  208 
of  the  advancing  head,  214 
of   the   after-coming   head,   218 
technic,  215 
preliminary  conditions,  230 
prognosis,  240 
spondylotomy,  238 
Emphysema,    from    forcing    air    into 
lungs,  431 
in  rupture  of  the  uterus,  312 
Engagement  of  the  head  in  forceps 

delivery,  175 
Enlargement      of      the      pelvis,     by 
springing     the     sacroiliac 
joint,   30,  164,  196,  393 
permanent      through     operation, 
106 
Enucleation  of  the  eye  in  delivering 

with  forceps,  204 
Epiphyseal   separation,   167 
Episio"t,omy,   138,   158,   161,   192,   199, 
240,  280,  332 
suturing,  285,  336,  365 
Equipment,  25 
Erb's  palsy,  204 

Ergot,  use  of,  in  delivery  of  second 
twin,  355 
in  inertia  uteri,  44 
in  postpartum  hemorrhage,  300 
Erosion  of  the  tube  in  extrauterine 

pregnancy,  436 
Esmarch    bandage,    use    of,    in    acute 

anemia,  306 
Ether  narcosis,  35 
Etiologic    management    of    abortion, 

424 
Etiology  of  cervical  lacerations,  316 
of    extrauterine   pregnancy,   434 
of  perineal  lacerations,  325 
of  vaginal  lacerations,  319 


INDEX 


451 


Etiology — Cent  'cl 

of  rupture  of  the  uterus,  308 
of  vulval  lacerations,  325 
Evisceration   {see  Exenteration) 
Exenteration,    238 
Exhaustion  during  labor,  396 
Expectant     treatment     in     cerebral 
hemorrhage,  169 
in      occipitoposterior      position, 
365 
Expression,  in  breech  positions,  164 
Kristeller's  method,  206 
of  the  after-coming  head,  164 
of  the  fetus,  204 
of  the  placenta,  290 
Extemporized   matrix   in    abdominal 

pregnancy,  437 
Extension    of    the    arms    in    breech- 
birth,  161 
External  version,  on  the  breech,  119 

on  the  head,  117 
Extraabdominal    section    of    uterus, 

257 
Extraction,  142 

after  perforation,  220 
applied  to  both  feet,  152 
applied  to  the  breech,  153 
with  blunt  hook,  154 
with  finger,  153 
with  Kiistner  's  hook,  157 
with  sling,  155 
difficulties  of,  161 
expression  while  extracting,  164 
freeing  the  arms,  146,  161 
injuries   accompanying,   166 
lacerations   of,   166 
preliminary  conditions,   141 
prognosis,   169 
technic  of,  142 
with  bone  forceps,  224 
with    the    cranioclast,    223 
Extraperitoneal     cesarean      section, 
266 
steps    of    the    operation,    266, 
267 
Extraperitoneal    treatment    of     the 
pedicle,    Porro    operation, 
271 
Extrauterine  pregnancy,  434 

after  removal  of  the  uterus,  438 
clinical  aspects,  435 
complicating   extrauterine   preg- 
nancy, 438 
diagnosis  of,  438 
etiology  of,  434 
treatment  of,  439 


Extravasation  of  blood,  into  the  ab- 
dominal cavity,  436 
intracranial,  168,  430 
paravaginal,   320 
retroplacental,  348 
Extremities,  injuries  of,   167 
prolapse  of,  114,  364,  392 
recognition  of,  129 
reposition  of,   114 
Eye  affections  in  nephritis,  65 
injuries  from  forceps,  204 

F 

Face   presentation,   366 

cesarean  section  in,  366 
conversion  of,  into  vertex,   108, 

366 
forceps  in,  366 
mechanism  of,  366 
perforation    of,   366 
unfortunate  evolution   of,  366 
version  and  extraction  in,  366 
Facial   paralysis,  204 
Fallopian  tube,  pregnancy  in,  435 
False   passages,  made   with   the   for- 
ceps, 199 
made   with   the   perforator,   225, 
226 
Faust's  pelvimeter,  386 
Feces   appearing   in  the   vagina,   sig- 
nificance  of,  323 
Feet,   position   of,   in   transverse   po- 
sitions, 124 
in  vertex  positions,   124 
Femur,  epiphyseal  separation  of,  167 
fractures  of,  167 
luxations  of,  168 
Fetal   heart   sounds,  47 

in  prolapse  of  the  cord,  116 
variations   of,  47,   171 
mortality  in  forceps  delivery,  201 
Fetor  in  abortion,  417 
Fetus,  removal  of,  in  abortion,  423 
Fever,  in  abortion,  421 

intrapartum,  38 
Fibromyoma   {see  Myoma) 
Fistula,    cure    of,   not    to    be    under- 
taken during  puerperium, 
321 
due  to  pressure,  323 
ureterovaginal,  316 
urethrovaginal,   105  • 
uteroureteral,  316 
vesicovaginal,  105 
Flat    pelves,    head    engagement    in, 
390 
pubiotomy  in,  95 


452 


INDEX 


Foot,  bringing  down,  in   extraction, 
129,   133,   144 
bringing    down    "botli   feet    in    ex- 
traction, 152 
deliverv    of    foot    through    cervix, 

135,  137,  3-45 
extraction  by  botli  feet,  152 
extraction  by  one  foot,  144 
grasping  of,  in  version,  129 
prophylactic   delivery   of,   343 
recognition  of,  by  touch,  129 
Foramen        magnum,        perforation 

through,  219 
Forceps,  abortion,  424 

and  version  compared,  394 
obstetric,  171 

application    of,    froutooccipital, 
"      204 
in  brow  presentation,  193,  367 
in  contracted  pelves,  395 
in  cesarean  section,  264 
in  face  presentation,  192,  366 
in  hydrocephalus,  175,  411 
in  oblique  diameter,  186 
in   oceipitoposterior  positions, 

190 
in  prolapse  of  an  arm,  199 
in   prolapse   of   the  cord,   199, 

374 
in    vaginal    cesarean    section, 

283 
in  vertex  positions,  178 
to  after-coming  head,  165,  199 
to  the  breech,  200 
to  the  decapitated  head,  239 
axis-traction,  197 
compression  with,  181 
dithculties  in  use   of,  199 
description  of,  171,  197 
high  application  of,  194 
indications  and  conditions,  171 
in    abnormal    positions    of    the 

head,  190 
in  the  birth  of  twins,  357 
low  application  of,  177 
AIcLane-Tucker  instrument,  171, 

196 
method  of  application,  176 
most  favorable  situation  for  ap- 
plication,  175,   177 
narcosis  in  forceps  delivery,  177 
preliminary   conditions,   173 
prognosis,  200 
removal  of,  184,  198 
Simpson  pattern,  171 
slipping  of,  199,  202 
supportino    the    perineum,    183, 
184^' 


Forcej)S,    obstetric — Cont  'd 

Tarnier's    instrument,   197 
technic,   176 

traction  with,  182,  191,  195,  196 
trial  application  of,  193 
Forelying  of  the  cord,  368 
Forewaters,  375 

Foul-smelling  discharge  in  abortion, 
417 
in  parturition,  39 
Fractures,  of  the  clavicle,  167 
of  the  humerus,  161,  167 
of  the  lower  jaw,  169 
of  the  radius  and  ulna,  167 
of  the  skull,  168,  204 
of  the  thigh,  167 
through  extraction,  161,  167 
treatment,    168 
Freeing'  the  arms,  161 
Fritsch's     method     of     forcing    the 
head      into      engagement, 
205 
Funnel-shaped  pelves,  95,  376 

a 

Galvanic    reaction    of    degeneration, 

168 
Gangrene  of  the  bladder,  55 
Gas  formation  in  the  uterus,  39 
Gauze   pack   in   abdominal    cesarean 
section,  251 
tampon,  in  abortion,  419 

in  reducing  inversion  of  uterus, 
299 
Gelpi's  tenaculum  forceps,  333 
Generally  contracted  pelves,  376 

head  engagement  in,   390 
Genital  cleft,  325 
tumors,  ovarian,  402 
uterine,  404,  407 
vaginal,  408 
vulval,  408 
Gigli  saw,  97,  104 
Gloves,  preparation  of,  21 
Gonorrheal  infection,  408 
bartholinitis,   409 
condylomata,  409 
Grasping  the  feet,  for  extraction,  144 

for  version,  129 
Gyuecologic   procedures   accountable 
for    parturitional    difficul- 
ties, 244 

H 

Habitual    death   of  the   fetus   as   an 
■    indication    for    induction 
of   premature  birth,   55 


INDEX 


453 


Hammersclilag,   104,   273,   285 
Hand,  dilatation  of  the  cervix  with, 
82,  297 
disinfection,   22 

introduction   of,  into   birth   canal, 
122 
Hanging  belly,  395 
Hanging    position    {see    Walcher   po- 
sition) 
Head,     after-coming,     difficulties    in 
delivery  of,  164 
delivery    of,     after     decapitation, 
230 
when  coming  last,  150,  164 
with  the  forceps,  165 
engagement  of,  175 
fracture  of  lower  jaw,  169 

of  skull,  168 
hematoma  of,  168 
hemorrhage   into   meninges,   168 
indentation   of  parietal  bone,   168 
molding  of,  176,  389,  390 
positions  and  prolapse  of  the  cord, 

372 
rupture  of  cranial  vessels,  168 
trauma  of  the   scalp,   168 
Headless  trunk,  extraction  of,  236 
Heart        affections,        compensatory 
changes       during       preg- 
nancy, 38,  61 
during  labor,  61 
during  pregnancy,  60 
during  the  puerperium,  61 
treatment,  62 
sounds,  47 
Hegar's    cervical   dilatation,    71 
Hematocele     in     extrauterine     preg- 
nancy, 436 
Hematoma,     after     pubiotomv     and 
symphysiotomy,  106 
in  cervical  tears,  316 
in  extrauterine  pregnancy,  436 
in  forceps  delivery,  204 
in  rupture  of  the  uterus,  312 
in  vaginal  lacerations,  320 
infection  of,  106 
intracranial,  169 
of  the  scalp  and  face,  168 
retroplacental,   284 
treatment  of,  322 
Hemophilia  in  pregnancy,  67 
Hemorrhage,   between    the    folds    of 
the  broad  ligament,  436 
in  abortion,  417 
in  cesarean  section,  274 
in  extrauterine  pregnancy,  436 


Hemorrhage — Cont  'd 

in  lacerations   of  the  cervix,   166, 

316,  348 
in    lacerations    of    the    vulva    and 

vagina,  320 
in  placenta  previa,  347 
in    premature    separation    of    the 

placenta,  348 
in  rupture  of  the  uterus,  311 
in  the  third  stage  of  labor,  294 
into  the  meninges,  168 
into   the   peritoneal   cavity,  436 
under  the  peritoneum,  312 
Hernia  after  cesarean  section,  271 
after  pubiotomy   and  symphysiot- 
omy, 108 
High   elevation   of   the  pelvis  in  re- 
position maneuvers,  28 
extension   of  the   arms,   161 
forceps  operation,  194 
Hofmeier's  impression,  194,  204 
Honing 's  method  of   expressing  the 

ovum,  423 
Hook,  blunt,  154,  156 

Braun's  decapitation,  230 
extraction  with,  154 
Kiistner's  breech  hook,  157 
Smellie's  blunt  hook,  156 
sharp  hook,  use   of,  in  delivering 
the  anencephalic  fetus,  410 
in     delivering    the     decapitated 
head,  239 
use  of  hooks  in  general,  159 
Hospital     advantages,     in     cesarean 
section,    246 
in  contracted  pelves,  396 
in   eclampsia,   398 
in  pubiotomy     and  symphysiot- 
omy,   96 
in  rupture  of  the  uterus,  314 
Hot  baths  in  eclampsia,  400 

douches     in     postpartum     hemor- 
rhage, 300 
intrauterine     irrigation    following 
manual  detachment  of  the 
placenta,   296 
irrigation     in      vaginal      cesarean 

section,  284 
packs  in   eclampsia,  400 
Humerus,    epiphvseal   separation    of, 
167 
fractures  of.  161.  167 
luxations   of,   167 
Hydatidiform  mole,  51,  422 
Hydramnion,   acute,   55 
as  a  cause  of  inertia,  45 
in  twins,  45 
treatment  by  puncture,  71 


454 


INDEX 


Hydroceplialus,  411 

as  a  causation  of  uterine  rupture, 

310,    411 
diagnosis  of,  411,  413 
prognosis,   413 
statistics,    411 
'  treatment,  411 

forceps  delivery,  175,  411 

paracentesis,  411 

perforation      and      cranioclasis, 

411 
when  head  comes  last,  412 
when  head  presents,  411 
Hydroencephalocele,  412 
Hydromeningocele,  412 
Hydrostatic     bags      (see     Metreuryn- 
ter) 
Hydrothorax,  fetal,   239 
Hyperemesis   gravidarum,  49 

as   an   indication   for   interrupt- 
ing pregnancy,  49 
treatment,  51 
Hypodermoclysis,        in        combating 
anemia,  304 
in  eclampsia,  400,  401 
in  hyperemesis  gravidarum,  51 
Hysterectomy,   in   abortion,   418 
in  carcinoma,  407 
in  cesarean  section,  271,  274 
in  rupture  of  the  uterus,  315 
Hysterotomy  in   operating   for   ova- 
rian tumors,  402 


Iliosacral  joint,  rupture  of,  203 
Imbrication    of    the    bladder    in    ce- 
sarean section,  266 
Impaction  of  the  fetus  in  cross-birth, 

228 
Impeded   birth,    consequent    changes 

in  uterus,  229 
Impression  of  the  head,  Hofmeier's 
method,  194,  204 
Mueller's  method,  59 
Veit-Smellie's  method,  164 
Incarceration   of   the   gravid  uterus, 

56 
Incision,    in    cesarean    section,    250, 
269 
in  extrauterine  pregnancy,  440 
in  fat  patients,  272 
in  repeated   operations,  272 
in  vaginal   cesarean   section,   282 
of  the  cervix,  166,  374 
of  the  perineum  (see  Episotomy) 
of  the  OS  uteri,  166 
of  the  uterus,  269,  273 


Incomplete  abortion,  417 

laceration  of  the  perineum,  326 
rupture  of  the  uterus,  312 
Increased     intraabdominal     pressure 
as    the    immediate    cause 
of    rupture    in    extrauter- 
ine pregnancy,  436' 
supplv  of  blood,  effect  on  tumors, 
402 
Indentation  of  the   head,   168 
Indications    and   conditions,   general 
discussion   of,   37-48 
in    abdominal    cesarean    section, 

196,  243,  244,  245 
in  decapitation,  228 
in   embryotomy,   230 
in  expression,  206 
in    forceps    delivery,    171,   196 
in    interruption     of    pregnancy, 

49-67 
in  perforation   and   cranioclasis, 

196,  199,  208,  209 
in'   pubiotomy    and    symphysiot- 
omy, 94,  196 
in  radical  cesarean  section,  269 
in  vaginal  cesarean  section,  278 
Induced  rest  during  labor,  134 
Induction,  of  abortion,  67 

of  premature  birth,  72 
Inertia   of  the   uterus,  during  labor, 
42 
during  third  stage  of  labor,  292 
Inevitable   abortion,  417 
Infection,  38 
in   abortion,  418 
intrapartum,  40 
Infusion,    subcutaneous,   303 
in  anemia,  304 
in  eclampsia,  400 
Injuries,    from    slipping    of    forceps, 
202 
in  dilating  with  the  Bossi  and  sim- 

ilar  instruments,  87 
in  extraction,  166 

to  the   child,   167,  168 
to  the  mother,  166 
in  forceps  delivery,  201 
to  the  child,  203 
to  the  mother,  201 
in     manual     detachment     of     the 

placenta,  297 
in     perforation     and    cranioclasis, 

226 
in  pubiotomy  and  svmphvsiotomy, 

104 
in  removina'  the  ovum  in  abortion, 

425 
in  vaginal   cesarean   section,  282 


INDEX 


455 


Injuries — Cont'd 
in  version,  138 
Instillations  into   the  rectum,  51 
Instruments,  list  of  obstetric  instru- 
ments, 31 
preparation  and  care  of,  32 
Instruments   used,   in   abdominal   ce- 
sarean section,  248 
in  dilating  the  cervix,   78,  79,  83, 

87 
in  embryotomy,  230 
in  forceps  delivery,  176 
in    lacerations    of    the    vulva    and 

perineum,  332 
in    perforation     and     cranioclasis, 

211 
in  vaginal  cesarean  section,  279 
Interlocking  of   twins,  355,  357 
Internal  pudic  artery,  93 
version,   120 

indications,   120 
preliminary  conditions,  120-130 
technie,  121 
Intraabdominal    pressure    in    expul- 
sion of  placenta,  288 
section  of  the  uterus,  257 
Intracranial  hemorrhage,  169,  430 
Intrapartum   fever,   38 

infection  as  an  indication  for  radi- 
cal cesarean  section,  269 
Intrauterine   asphyxia,   109 
Introducing  the  hand  in  version,  122 
Introducing    the     metreurynter,    73, 

80 
Inversion  of  the  uterus,  298 
Iodized   gauze,  preparation   of,  34 
Iodoform   gauze    tampon,   use    of   in 
abortion,  419 
in   atony   of   the   uterus   follow- 
ing section,  284 
in  rupture  of  the  uterus,  314 
Irrigation  of  the  uterus,  after  man- 
ual   detachment     of     the 
placenta,  296 
in  atony,  284 
Irrigation   cannula   for   washing  out 

brain    substance,   211 
Isthmus  of  the  cervix,  263 


Jaw,  fractures  of,  169 
Justo  major  pelves,  378 
Justo  minor  pelves^  376 

K 

Kelly,  436 

Key -hook   (see  Decapitation  hook) 


Kiwisch-Martin  trephine,  211 

Kitchen  table,  improvised  for  oper- 
ations in  the  home,  248 

Knee-chest  position,  29 

in     reducing     the     incarcerated 

gravid  uterus,   57 
in  reposition  of  pedunculated  fi- 
broids, 405 
in    reposition    of    the    prolapsed 
cord,  115,  371,  373 

Koenig,  266 

Koenigsberg  clinic,  41,  396 

Kraurosis  as  an  etiologic  factor  in 
lacerations  of  the  introi- 
tus,  325 

Krause,  bougie  method  of  inducing 
labor,   73 

Kristeller  's  method  of  expressing 
the  fetus,  206 

Kiistner's  breech  hook,  157 

Kyphotic  pelves,  377 

head   engagement  in,  391 

L 

Labor  pains,  alleviation  of,  34 

effect     on     lower     segment     of 

uterus,  394 
stimulation    of,   44 
Lacerations,   from   forceps,   201,   319 
from    symphysiotomy    and    pubiot- 

omy,  105,  320 
from  version,  138 
of  the   bladder,   321 
of  the  cervix,  166,  202,  316 
of   the  introitus,   138 
of  the  rectum,  321 
of  the  vagina,  319 
of  vessels,  320 

of  vulva  and  perineum,  166,  325 
Laminaria  digitata,  421 
Laparotomv,     in     cesarean     section, 
250 
in   ovarian  tumors,  403 
in  retroflexed  gravid  uterus,  313 
in  uterine  carcinoma,  407 
in  uterine  myoma,  406 
Laryngeal  tuberculosis,  64 
Larynx,  catheterization  of,  431 
Lateral  position,  in  labor,  328 

in   manual   delivery   of  the  pla- 
centa, 297 
Latzko,      extraperitoneal      cesarean 

section  of,  267 
Leavitt's  dilator,  74,  85 
Legholder,    improvised    with     sheet, 

27 
Leucemia  in  prognancv,  67 
Leopold,  274 


456 


INDEX 


Linea  innominata,  relation  of  to  en- 
g-agement  of  the  head,  175 

Line  of  traction,  in  extracting  with 
the   cranioclast,   223 
in    forceps    delivery,    180,    182, 
191,  193,  196 

Lithopedion,  437 

Lithotomy  position,  164 

Living    child,   importance   of   know- 
ing if  it  be  alive,  95 
perforation  of,  208,  209,  395 

Local  fetor,  treatment  of,  407 

Locking  the  forceps,  179 

Lordosis,  395 

Lungmotor,  use  of,  in  asphyxia,  432 

Lysol,  use  of,  24,  122 

M 

McClintock's  axis-traction  bar,  171 
McLane-Tucker  forceps,  196 
Mack,  Alonzo  E.,  245 
Manipulation,    Brose's,    in    version, 
135 
Crede's,  in  expressing  the  placenta, 

290 
Fritsch's,  of  forcing  the  head  into 

engagement,  205 
Hofmeier's,   of    forcing    the    head 

into  engagement,  204 
Honing 's,  of  expressing  the  ovum, 

423 
Kristeller's  expression,  206 
Prague,    in    delivering    after-com- 
ing head,  165 
Siegemundin 's,  in  version,  135 
Thorn's  in  version,  108,  366,  367 
Veit-Smellie,   in    delivering   after- 
coming  head,   150 
Weigand-Martin  Wanckel,    in    de- 
livering after-coming 
head,    164 
Mauriceau-Levret,     in     delivering 
after-coming  head,  150 
Macerated  fetus,  craniotomy  in,  239 
decapitation  in,  239 
in   abdominal   pregnancy,   437 
Malformations  and  anomalies,  of  the 
fetus,  410 
anencephalus,  410 
double   monsters,   239,  414 
hydrocephalus,  411 
hydroencephalocele,  412 
hydromeningocele,    412 
hydrothorax,  239 
outgrowths    on    the    buttocks, 

239 
other  teratomata,  413 


Malformations  and  anomalies — Cont'd 
of   the   mother,   410 
double  uterus,  410 
double   vagina,   410 
Manual  detachment  of  the  placenta, 
294 
dilatation  of  the  cervix,  82,  297 
reduction      of      the      incarcerated 
gravid  uterus,  57 
Massage   of  the  heart  in  eclampsia, 
401 
of  the  uterus  in  postpartum  hem- 
orrhage, 300 
Mauriceau-Levret    method    of   deliv- 
ering   after-coming    head, 
150 
Meconium,  discharge  of,  46,  171 
Medulla    oblongata,    penetration    of, 

204 
Megaloblasts,  67 
Mensuration  {see  Pelvimetry) 
Mertz,  308 
Metal  dilators, 
Bossi's,   83 
Hegar's,  71 
Leavitt's,  74 
Methods,   Fritsch's,    of    forcing    the 
head  to  engage,  205 
Hofmeier's  impression,  205 
of   determining  whether  the  head 

is  advancing,  175 
of  dilating  the  cervix,  77-92 
of  estimating  the  size  of  the  fetal 

head,  59 
of  inducing  abortion,  67-71 
of  inducing  premature  birth,  72-75 
Metrophlebitis,  418 
Metreurynter,  use   of,   in   eclampsia, 
399 
in  placenta  previa,  346 
in  prolapse  of  the  cord,  115,  116 
in  transverse  positions,  116,  363 
in  vaginal  cesarean  section,  282 
technic,  78 
to  induce  labor,  73 
Michaelis'  rhomboid,  379 
Michel's  skin   clips,  256 
Microeytes,   67 

Molding  of  the  head,  176,  390 
Mole,  hydatidiform,  51,  422 

of  extrauterine  pregnancy,  436 
Momburg's  tube,  300 

use    of.    in   atony    of    the    uterus, 
274 
in      postpartum     hemorrhage, 

300 
in  rupture  of  the  uterus,  314 
Moreellement  in  embryotomy,  239 


INDEX 


457 


Morphine,  to  give  rest  in  labor,  42 

Morbidity  following  forceps  deliv- 
ery, 201 

Mueller's  method  of  estimating  the 
size  of  the  fetal  head,  59 

Multiple  birth,  353   {see  Twins) 

Murphy_,  51 

Mutilation  of  the  child  (see  Embry- 
otomy) 

Myoma  of  the  uterus,  404  (see  also 
Uterus,  myomata  of) 

N 

Naegele    perforator,    211,    217,    231, 

238 
Narcosis,   a   valuable   adjunct   in  la- 
bor, 331 
in  cesarean  section,  275 
in  curetting  the  uterus,  423 
in   eclampsia,  399 
in  embryotomy,  214,  231 
in  extraction,  153 
in  forceps  delivery,  192 
in  Hofmeier's   impression,   205 
in  inversion  of  the  uterus,  299 
in  manual  delivery  of  the  placenta, 

295 
in  placenta  previa,  347 
in  repairing  lacerations  of  the  per- 
ineum, 332 
in  the  reposition  of  tumors,  402 
in  version,  121,  132,  359 
to  quiet  the  patient's  fears,  172 
Navel  cord  (see  Umbilical  cord) 
Neck,  extended  arm  about,  162 
Nephritic  tension  in  eclampsia,  401 
Nephritis,   65 

as   an  indication   for   interrupting 

pregnancy,  65 
sight   disturbances   in,   65,   66 
Nerves,  injuries  of,  during  labor,  168 
Newborn,  asphyxia  in,  426 
Nonengagement   of   the   head,   120 
Nonunion   of    the   symphysis   follow- 
ing symphysiotomy,  106 
Normal  blood-loss  in  childbirth,  293 
Nufer,  242 
Nutrient  enemata,  51 

O 

Oblic^ue  application  of  forceps,  186 
Obliquely  contracted  pelves,   376 

head  engagement  in,  391 
Observance  of  correct  mechanism  as 

a    prophylactic     measure, 

327 


Obstacles,  to  the  birth,  409 
to  cesarean  section,  244 
to  embryotomy,  238 
to  version,  121 
Obstetric  equipment,  25 
field  of  operation,  21 
postures,  25 
bed,  25 
Obturator  artery,  94 
Occipital  bone,  injuries  of,  in  forceps 

delivery,  204 
Occipitoposterior       positions,       190, 
365,  396 
management    of,    365 
perforation  and   cranioclasis  in, 

209 
use  of  forceps  in,  190 
prognosis,  365 
Olhausen,  274 

Opening     peritoneal     cavity     in    ex- 
trauterine pregnancy,  440 
Operating  table,  27 
Operations  designed  to  increase  the 
pelvic   diameters    (see   Pubi- 
otomy        and       Sjanphysi- 
otomy) 
Ophthalmic  reaction  in  tuberculosis, 

64 
Organic    heart    disease,    as    an    indi- 
cation    for     interrupting 
pregnancy,  60 
treatment  of,  62 
Os  pubis,  anatomy  of,  93 
Os  uteri,  dilation  of,  69-71,  141 
incisions  of,   89,   166,  175 
state  of,  in  impending  abortion, 
416 
Osteomalacic  pelves,  243,  378 

as  an  indication  for  radical  ce- 
sarean section,  269 
Ovarian  tumors,  402 

as  an  obstruction  to  birth,  402 
history  of,  403 
in  pregnancy,  403 
operations  for,  402 
reposition  of,  402 
statistics,  403 
treatment,  403 
twisted   pedicle,   403 

simulating   extrauterine   preg- 
nancy, 438 
Ovariotomy,    abdominal,   402 

vaginal,  403 
Oviduct,   relation    of,   to   pregnancy, 

435 
Oxygen,  inhalation  of,  in  eclampsia, 

400 
Oxygenation  of  the  fetal  blood,  46 


458 


INDEX 


Packing  the  vagina  in  abortion,  419 
Pacjuelin  cautery,  409 
Pain,  in  abortion,  416 

in  extrauterine  j)regnaney,  438 
Pale  appearance  of  death  in  asphyx- 
ia, 426 
Palliative  treatment  in  carcinoma  of 

the  uterus,  407 
Paralvsis,    Erb 's,    after    forceps    de- 
livery, 204 
of  the  facial   nerve   after  forceps 
delivery,  204 
Parametrium,  exudate  into,  317,  418 
lacerations  into,  316 
scar  formations  in,  322 
Parietal  bone  engagement,  390 
Parturient  canal,  21 
Patient,  preparation  of,  23,  115 
Patient    waiting,    a    safe    policy    to 

pursue,  394 
Paunch  bellv,  as  a  cause  of  inertia, 
43 
in   contracted  pelves,  395 
Pedicle,   twisting   of,   in   ovarian   tu- 
mors, 403 
Pelvic    inclination    as    an    etiologic 
factor    in    lacerations    of 
the  introitus,  325 
measurements,  93 
Pelvimeters,  Breisky's,  382,  386 

Faust's,  386 
Pelvimetry,  381 

external  measurements,  383 

anteroposterior  of  outlet,  385 
external     conjugate    (Beaude- 

loccpie)  383 
intercristal,  383 
interspinal,   383 
intertrochanteric,    383 
intertuberal,  385 
right  and  left  oblique,  384 
internal  measurements,  386 
diagonal  conjugate,  386 
true  conjugate,  386 
Pelvis,  contractions  of,  376 

abdominal    cesarean    section    in, 

243,  386 
absolute,    243,   378 
classification,   376 
conduct  of  labor  in,  394 
diet  in,  395 
embryotomy  in,  387 
enlarging    operations,    93 
induced  labor  in,  388,  395 
moderate,  378 


Pelvis — Cont  'd 

Ijcndulous  abdomen  in,  395 
perforation   and   cranioclasis  in, 

388 
pubiotomy    and    symphysiotomy 

in,  388 
relative,  244,  378 
rupture  of  the  uterus  in,  394 
spontaneous  birth  in,  391 
statistics,  396 
tendency    to    prolapse    of    cord 

and  extremities  in,  392 
treatment  in,  386 
Walcher  position  in,  393 
Pendulous     abdomen    in    contracted 

pelves,  395 
Perforation  and  cranioclasis,  208 
difficulties,  225 

general    indications    and    condi- 
tions, 208 
in  deflections  of  the  head,  365 
indications   for,   in   the   advanc- 
ing head,  214 
indications    for,    in    the    after- 
coming  head,  164,  412 
in  face  positions,  193 
in  hydrocephalus,  217,  412 
in      occipitoposterior     positions. 

365 
in  twins,  356 
instruments  used,  211 
method  of  procedure,  210 
the  head  coming  first,  214 
the  head  coming  last,  218,  412 
preliminary  conditions,  209,  388 
prognosis,  226 
statistics.  226 
through  the  orbit,  366 
with  the  perforator,   215,   217 
with  the  trephine,  216 
with  the  trocar,  217 
of  the  uterus,  422 
Perforators,  Kiwiseh-Martin,  212 
Naegele,  211,  231 
Smellie,  211,  231 
Perineal     section     (see     Episiotomy) 
support,  183,  184 

in  forceps  delivery,  183 
in  the  dorsal  position,  331 
in  the  lateral  position,  330 
suturing,  333 

in  central  rupture,  336 
in  complete  rupture,  336 
in  episiotomy,  336 
in  incomplete  rupture,  333 
tears,  332 
central,   336 


INDEX 


459 


Perineal  tears — Cont  'd 
complete,  336 
incomplete,  333 
Perineum,  lacerations   of,  325 
atypical,   339 
central,  336 
complete,  336 
course  of,  325 
diagnosis  of,  327 
etiology  of,  325 
incomplete,   333 
symptoms,  325 

treatment,    prophylactic,    327 
reparative,  332 
Pernicious  anemia,  67 
Phthisis  during  pregnancy,  64 
Physiology    of    cleavage    and    expul- 
sion of  the  placenta,  287 
Pituitary  extract,  use  of,  before  em- 
ploying forceps,  172 
following  cesarean  section,  268 
in   cesarean   section,  252,  260, 

284 
in    delivery    of    second    twin, 

355 
in  hydrocephalus,  411 
in  inertia,  44,  45 
in     postpartum      hemorrhage, 
300 
Placenta,  anomalous  form  and  size  in 
multiple  births,  355 
Crede  expression  of,  290 
delivery    of    in    cesarean    section, 

252,  269 
disturbances  of  expulsion,  292 
external  manipulation  of,  290 
hemorrhage   before   birth   of,   293, 

348 
hemorrhage   from,   in   cesarean   sec- 
tion, 273 
in  extrauterine  pregnancy,  437 
low  implantation  of,  109 
manual  delivery  of,  294,  355 
normal  delivery  of,  288 
premature   detachment   of,   348 
previa,  340 

as    an    indication    for    cesarean 

section,   278,  342 
cervical  tears  in,  342 
child's  body  used  as   a  tampon 

in,  343 
colpeurysis  in,  91 
combined  version  in,  345 
dangers  of  rapid  dilatation,  340 
early  signs  of,  347 
fatality,   340,   345 
general  remarks  on,  347 
metreurysis   in,   346 


Placenta  previa — Cont  'd 

draining  the  amnion,  343 
treatment,  343 
various  forms  of,  345 
version  and  extraction  in,  347 
prolapse  of,  351 

retention  without  bleeding,  294 
signs  of  separation,  287,  293 
Placental     implantation     in     extra- 
uterine  pregnancy,  435 
period    (see   Third  stage  of  labor) 
retention,  294 
Pneumonia  during  pregnancy,  38 
Pneumothorax  from  forcing  air  into 

lungs,  431 
Poikilocytes,  67 
Point     of    rupture    in     extrauterine 

pregnancy,  436 
Porro,  242 

operation,  cesarean   section,   269 
Portio   vaginalis,   tumors   of,   244 
Position,  of  the  accoucheur,  182 
of   the   child,   influenced   by   myo- 

mata,  404 
of  the  patient  dorsal,  or  lithotomy, 
164 
high  elevation  of  hips,  28 
in    correcting    faulty    attitudes, 

109 
in  forceps  delivery,  177 
in  labor,  25 

in  performing  decapitation,  231 
in  reposition  of  the  cord,  115 
in   symphysiotomy  and  pubioto- 
my,  96 
knee-chest,  29 
lateral,   28,   328,  329,  330 
Trendelenburg,  28 
Walcher^  30,  164,  393 
Posterior    position    of    the    occiput, 
365 
correction  of,  with  forceps,  190, 
365 
by  iDOsture,  365 
mechanism   of,   365 
statistics,  192,  365 
Posterior  parietal  bone,  engagement 

of,  390 
Postnatal  atelectasis,  433 
Postpartum    hemorrhage,    300 
checking    the,    300 
combating  the   anemia,  302 
Potassium    permanganate,    disinfect- 
ing       and         deodorizing 
douches   of,  407 
Pouch    of   Douglas,    283 
Prague  method  of  delivering  the  af- 
ter-coming head,   165 


460 


INDEX 


Pregnancy,  extrauterine,  434 
Preliminary    conditions,    in    abdomi- 
nal cesarean  section,  279, 
388 
in    artificial    dilatation    of    the 
cervix,  77 
with  the  child's  body,  77 
with  the  hand,  83 
with  metal  dilators,  84 
in  breech-birth,  141 
in  conversion  of  deflected  posi- 
tions of  the  head,  108 
in  forceps  delivery,  173 
in  general,  48 
in  induction  of  labor,  388 
in  Kristeller's    expression,    207 
in  perforation  and   cranioclasis, 

388 
in     pubiotomy     and    symphysi- 
otomy, "94,  95,  107,  388 
in  vaginal  cesarean  section,  278 
preparations,    for    abdominal     ce- 
sarean   section,    247,    250, 
269 
for  delivery,  23,  24,  115 
for  manual  delivery  of  the  pla- 
centa, 295 
for     vaginal     cesarean     section, 

279 
in  extrauterine  pregnancy,  440 
Premature  birth,  artificial  induction 
of,  72 
methods  of  inducing,  72,  73,  74 
prognosis  in,  76 
interruption      of     pregnancy      {see 

Abortion) 
sej)aration  of  the  placenta,  348 
as  an  indication  for  vaginal  ce- 
sarean section,  278,  350 
etiology,    symptoms,    and    treat- 
ment, 348 
in  hydramnion,  351 
in  twins,  351,  354 
prognosis,  352 

resemblance    to    rupture    of    the 
uterus,  248 
Presentation  by  the  brow,  367 

by  the  face,  108,  366 
Pressure  injuries  of  the   cervix  and 
vagina,  323 
diagnosis   of,   323 
etiology  of,  323 
prognosis    in,    324 
symptoms  of,  323 
treatment  of,  324 
necrosis,  324 


Pressure — Cont  'd 

on  head  in  head-last  births,  164 
Previous     parturitional     experience, 
knowledge     of,     essential 
in     contractions     of     the 
pelvis,  391 
Prochownik,  diet  of,  395 
Proctoclysis,  in  anemia,  305 

in  hyperemesis,  51 
Prognosis  in  abortion,  425 

in     abdominal     cesarean     section, 

274 
in   artificial   interruption   of  preg- 
nancy, 76 
in  breech-births,   169 
in  embryotomy,  240 
in  forceps  deliveries,  200 
in  lacerations  of  the  cervix,  318 
in  lacerations  of  the  vagina,  322 
in  lacerations   of   the   vulva     and 

perineum,  339 
in    manual    delivery    of    the    pla- 
centa,  297 
in    perforation     and     cranioclasis, 

226 
in  pressure  injuries,  324 
in  pubiotomy  and  symphysiotomy, 

104 
in  rupture  of  the  uterus,  312 
in  vaginal  cesarean  section,  285 
in   version,   137 
Prolapse  of  an  arm  in  face  presen- 
tations, 366 
of  an  extremity,  114,  364,  392 
of  the  bladder,  323 
of  the  cord,  240,  364,  366,  368,  392 
of  the   placenta,  351 
of    the    uterus    during    pregnancy, 
58 
Proliferation    rapid    under    influence 

of  gravidity,  407 
Prolonged  labor,  171,  172 
Prolonged  vaginal  douche  to  induce 

labor,   72 
Provisional   fistula   of   Eubeska-Sell- 

heim,  268 
Pubiotomy,  98 
after  Bumm,  101 
after  Doderlein,  98 
anatomy   of  symphysis  pubis,   93 
closed  operation,  101 
competing   operations,  95 
general   consideration,   94,   105 
indications  for,  94,  164 
in  face  positions,   193 
lacerations   accompanying,   105 
needle,  Bumm's,  101 
Doderlein 's,  104 


INDEX 


461 


Pubiotomy — Cont  'd 
open    operation,   98 
X^reliminary     conditions,     95,     107, 

388 
prognosis,  104 
remote  effects  of,  106 
statistics   and  results,   104 
subcutaneous,  101 
Pubovesical  space   (see  Eetzius,  space 

of) 
Puerperal  infection,  25,  38 

statistics,  25 
Puerperium,   after   cesarean   section, 
269 
after    pubiotomy    and    sympliysi- 

otomy,  106 
after  rupture  of  the  uterus,  314 
after  severe  lacerations,  336 
Pulmonary  and  laryngeal  tuberculo- 
sis as  indications  for  in- 
terrupting   gestation,    63, 
64,  65 
Pulmotor  in  asphyxia,  432 

in  eclampsia,  401 
Pulse,  disturbances  of,  in  anemia,  39 

in  infection,  39 
Puncturing    the    amnion    to    induce 
labor,   74 
the     sacrum     (accidentally)     v^^ith 
the  perforator,  226 
Pushing  upward  on  the  head  in  ver- 
sion,  133 
Pyelitis  during  pregnancy,  66 
Pyosalpinx    simulating    extrauterine 
pregnancy,  438 


Quinine  in  labor,  44 


Eachitic  flat  pelves,  95,  376 

Eachitis  fetalis,  413 

Eadical  operation   (cesarean),  269 

Eadiography,  167 

Eadius  and  ulna,  fractures  of,   167 

Eeaction   of   degeneration,  168 

Eectal    examination,    396 

Eectum,  carcinoma  of,  409 
lacerations  of,  321 

Eeducing    the    speed    of    expulsion, 
327 
the   size   of  the   child    (see  Embry- 
otomy) 

Eelative  proportional  value  of 
mother's  pelvis  to  that  of 
the  child's  head,  391 

Eelative  safety  of  symphysiotomy 
and  pubiotomy,   104 


Eeleasing    adhesions    in    performing 

cesarean  section,  273 
Eemoving  the   ovum,  423 
Eeparation   of  injuries,   166,   332 
Eeposition,  of  cord,  114,  115 
of  an  extremity,  111 
of  tumors,  402,  405 
of  uterus,  298 
Eesection  of  the  tube  in  extrauter- 
ine   pregnancy,   441 
Eespiration,    artificial,   in    asphyxia, 

430 
Eespiratory  effort  in  intrauterine  as- 
phyxia, 47,  171 
Eesponsibility    of    the    physician,    in 
artificial  abortion,  49 
in  obstetric  operations,  36,  208, 
277 
Eetention  of  the   dead  fetus,  55 
of  placental  parts,  294 
of     the     placenta     without     hem- 
orrhage,  294 
Eetinal   separation,   66 
Eetinitis  albuminurica,  66 
Eetroflexed  gravid  uterus,  55 

reduction  of,  57 
Eetroperitoneal     treatment     of     the 

pedicle^    269 
Eetroplacental   hematoma,   284 
Eetrovaginal   septum,  laceration   of, 

321 
Eetzius,  space  of,  94,  97,  260,  266 
Ehomboid   of  Michaelis,  379 
Eing  of  Bandl    (see  Bandl,  ring  of) 
Eobb  leg-holder,  28 
Eobert's  pelvis,  377 
Eoentgenology   (see  Eadiography) 
Eotation     in     breech-birth     to    free 
arms,  161 
in    face    presentations,    193 
Eubber    bags    for    dilating   purposes 
(see      Metreurynter      and 
Colpeurynter) 
Eubber    bandage,    use    of,    in    auto- 
transfusion,  306 
in     pubiotomy     and     symphysi- 
otomy, 96 
Eubber      gloves,      preparation      and 

sterilization  of,  22 
Eubber  tube  of  Momburg  (see  Mom- 
burg) 
Eubeska-Sellheim   method   of   drain- 
ing the  septic  uterus,   268 
Eupture,  of  bladder,  320 
of  cervix,  316 
of  liver,  168 
of  pelvic   articulations,  203 


462 


IXDEX 


Eupture — Cout  'd 

of   perineum,   336 

of  sacroiliac  joint,  203 

of   sympliysis   pubis,   203,  395 

of  tube  in  extrauterine  pregnancy, 
435 

of  vagina,  319 

of  vulva,  325 

of  uterus,   138,  229,   308 
Eupturing  tlie  amnion,  71 

S 
Sacroiliac  joint,  rupture  of.  203 
Sacrum,  penetration  of,  226 
Saenger,   242 
Sagittal  suture,  390 
Salpingitis,    simulating   extrauterine 

pregnancy,  438 
Salt    solution,    intravenous    infusion 

of,  203 
Sand  bag,  use  of,  in  atouv  of  uterus, 
■   302 
in  rui)ture   of  uterus,  314 
Saprophvtes    as    gas-forming   germs, 

39 
Saw-carrier    {see   Pubiotomy   needle) 
Sa^v  of  Gigli,  97,  104 
Scar  formations  of  cervix,  244 
of  OS  uteri,  410 
of  perineum,  325 
of  vagina,  244 
Seanzoni,    method    of    rotating    tlie 
head    with    the     forceps, 
193 
Scarification  in  edema  of  the  vulva, 

408 
Schatz,  method  of  correcting  deflec- 
tions of  the  head,  108 
Schauta,  274 
Sehroeder's     classification     of     pelvic 

contractions,  378 
Sehultze,    mode    of    placental    cleav- 
age, 287 
swinging  method   of  resuscitating 
the    newborn    child,    427 
Scissors,  Siebold's  231 
Scopolamin-morphin         half -narcosis 

{see  Twilight  sleep) 
Self -retaining  catheter,  321 
Sellheim-Eubeska,        uteroabdominal 

fistula,  268 
Separation   of   the   occiput   from  its 
basilar   connection,   204 
of  the  ovum  with  the  curette,  422 
of   placenta,   288 
manual,  294,  355 
with  finger,  421 
premature,  348 


Separation  of  placenta — Cont'd 
signs  of,  287,  293 
spontaneous,  287 
Sepsis,  38 

following  perforation  and  cranioe- 

lasis,  226 
in   abortion,  418 
in  cesarean  section,  268 
intrapartum,  -  40 
Septic  abortion,  418 

thrombus,  275 
Sequels   of   symphysiotomy    and   -\)Vl- 

biotomy,  106 
Sharp  hook,  use   of,  239 
Shocli    in     extrauterine     pregnancy, 

438 
Shoulders,  delivery  of,  184 
Side   position  in   manual   separation 
of  the  placenta,  297 
in  deliverv,  328 
Siebold's  scissors,  232,  238 
Siegemundin,  manipulation  of,  135 
Sight   disturbances,  65,  66 
Signs  of   cervical  lacerations,  316 
of  disturbed  placental  circulation, 

45,  46,  47 
of  intrapartum  infection,  40 
of  intrauterine   asphyxia,  171 
of  placental  separation,  287,  293 
of  pressure  injuries,  323 
of   rupture   of  uterus,   311 
Simon's  speculum,  74 
Simple  flat  pelves,  376 
Sims'  position  in  packing  vagina,  69 

in  prolapse  of  cord,  371 
Skin    emphysema    after    rupture    of 

the  uterus,  312 
Skin  irritation  in  asphyxia,  427 
•Skull,   compression   of,   with   cranio- 
elast,  224 
fractures   of,  in  extraction,  168 

with  forceps,  204 
spoon-shape  depressions   of,   169 
Sling,  use  of,  in  decapitation,  232 
in  extraction,  156 
in  version,  135 
Slinsf-carrier,  Bunge's,  156 
Slipping  of  the  forceps,  199,  202 
Smellie  hook,  156 
perforator,  211,  231 
-Yiet  method  of  delivering  after- 
coming  head,  150 
Space  of  Eetzius  {see  Eetzius) 
Spaeth,  242 

Spatial  inadequacv,  58 
Spina  bifida,  412  ' 
Spinal  anesthesia,  35 
Spondylolisthetic  pelves,  378 


INDEX 


463 


Spondylotomy,  238 

Sponge-holder,   use    of,   in   removing 

the   ovum,  424 
Spontaneous  abortion,  416 
Spontaneous     delivery     after .  pubi- 
otomy       and       symphysi- 
otomy, 97,  104 
Spoon-shaped     depressions     of     skull, 

169 
Spurious  labor  in  extrauterine  preg- 
nancy, 437 
Statistics     in     abdominal     cesarean 
section,  266,  274 
in    artificial   premature    birth,    59, 

76 
in  chorea  of  pregnancy,  66 
in  eclampsia,  401 
in  forceps  operations,  192,  200 
in     perforation     and    cranioclasis, 

226 
in  puerperal  fever,  25 
in  pubiotomy  and  symphysiotomy, 

104 
in  vaginal  cesarean  section,  285 
in  version,  139 
Stein-Mesnard  bone  forceps,  211,  224 
Stenosis  of  the  cervix  as  an  indica- 
tion    for     abdominal     ce- 
sarean section,  278 
Sterilization,    of    dressings,    33 
of  gloves,  21 
of  instruments,  32 
of  tuberculous  women,  65 
of  suture  material,  33 
Sternomastoid  muscle  as  a  guide  in 
perforating  the  after-com- 
ing head,  219 
■Stimulated  metabolism  in  pregnancy, 

402 
Strain    as    an    immediate    cause    of 
rupture     in     extrauterine 
pregnancy,  436 
Stroganoff's    treatment    of    toxemia, 

399 
Strong    pains,    essential    in    contrac- 
tions of  the  pelvis,  391 
Strophanthus  in  heart  disease,  62 
Subcutaneous  infusion,  in  acute  ane- 
mia, 304 
in  eclampsia,  400 
Submucous   myoma,  405 
Succenturia  placentae,  291 
Succulence    of    uterus    in    abortion, 

417 
Sudden  death  of  mother  as  an  indi- 
cation   for    cesarean    sec- 
tion, 245 


Sugar,  given  to  increase  labor  pains, 

50 
Supporting   the   perineum,   183,   185, 

327 
Suppressed    lochia    in    cesarean    sec- 
tion, 275 
Suprarenal    extract    after    cesarean 

section,  274 
Suprasymphyseal     cesarean     section, 
258 
delivery  of  the   child  in,  260, 

264 
extraperitoneal,  266 
suturing,  260 
technic  of,  258,  260 
transpei'itoneal,   263 
uteroabdominal  fistula,  268 
Supravaginal,     amputation     of     the 
uterus,  after  Porro,  270 
in   myoma,   406 
in  rupture  of  the  uterus,  315 
Surgical  ability,  importance  of,  246 
Sutures,  removal  of,  in  cesarean  sec- 
tion, 269 
Suturing     of     the     abdominal    wall, 
255,  256,  257,  260 
of  cervical  lacerations,  318 
of  episiotomy  wound,  336 
of  perineal  lacerations,  332 
of  the  complete  tear,  336 
of  the  incomplete  tear,  333 
of  the  ruptured  uterus,  314 
of   uterus    in    abdominal    cesarean 

section,   254,   260,   265 
of  uterus  in  vaginal  cesarean  sec- 
tion, 285 
of  vaginal  tears,  321 
Suture  material   in  abdominal   cesa- 
rean section,  254 
in  repairing  perineal  tears,  332 
in  vaginal  cesarean  section,  279 
preparation  of,  33 
Swinging    movements    of    Schultze, 

427 
Symphysis,  rupture  of,  203,  395 
Symphysiotomy,  96 
closed  method,  97 
competing  operations,  95 
open  operation,  96 
Symptom-complex    of    puerperal    in- 
fection, 39 
Symptoms  of  acute  anemia,  293 
of  cerebral  pressure,  426,  430 
of  lacerations  of  vagina,  320 
of  rupture  of  uterus,  310 


464 


INDEX 


Tait,  434 

Tampon,  disadvantages  of,  347,  420 
use  of,  in  abortion,  67,  419 
in  atony  of  uterus,  350 
in  inversion  of  uterus,  298 
in  lacerations  of  cervix,  166,  317 
in  lacerations  of  vagina,  322 
in  postpartum  hemorrhage,  301 
in  prolapse  of  cord,  369 
in  rupture  of  uterus,  314 

Tarnier,  242 

axis-traction   forceps,    197 

balloon,  80 
T-binder,  299 

Tearing  out  of  the  cranioclast,  225 
Technic  of  decapitation,  232 

of   exenteration,   238 

of  extraction,  142 

of  internal  version,  121 

of  vaginal  cesarean  section,  280 

Tents,  technic  of  their  use  in  abor- 
tion, 69,  420 

Teratoma,  413 

Termination    of    extrauterine    preg- 
nancy, 435 
Thigh  (see  Femur) 
Third  stage  of  labor,  287 
conduct    of,   288 
disturbances  of,  292 
Duncan's    mode    of    placental 

cleavage,  287 
expression    of    placenta,    290 
hemorrhages  of,  287,  293 
in  birth  of  twins,  355 
management  of  normal  deliv- 
ery of  placenta,  288 
manual   delivery   of   placenta, 

294 
physiology  of  placental  cleav- 
age and  expulsion,  287 
prognosis,   297 
prophylactic  measures,  299 
Schultze  's   mode   of  placental 

cleavage,  287 
signs  of  placental  separation, 

287,  293 
stricture    of    cervix    in,    292, 

293 
weak  labor  pains  in,  292 
Thorn's  manipulation,  108,  366,  367 
Threatened  abortion,  416 
rupture  of  uterus,  310 
Tracheal  catheter,  431 
rales,   400 


Traction,     continuous,     in     bringing 
away  the  mutilated  fetus, 
239 
on  the  arm  in  performing  decapi- 
tation, 232 
on  the  child's  body  in  perforating 
the  after-coming  head,  219 
on    the    foot    in    prolapse    of    the 

cord,  371 
test  in  high  forceps,  195 
to  the  axilla,  185 
with  the   cranioclast,   223 
with  forceps,  180,  191,  198 
with  axis-traction  forceps,  198 
Transperitoneal       cervical       section, 
Doderlein  's  operation,  263 
steps    of    the    operation,    263- 
266 
Transfusion    of   blood   in    acute  ane- 
mia, 305 
autotransfusion,  306 
Transverse  contraction  of  the  pelvis, 
377 
position,  358 

always  calls  for  help,  358 

as    an    indication    for    version, 

117,  120,  131 
complications  in,  228 
cord  and  arm  prolapse  in,  363 
external  version  in,  358 
frequency  of,  in  twins,  357 
internal  version  in,  363 
spontaneous  delivery  in,  363 
spontaneous  evolution  of,  358 
the   opportune  moment  of,  359 
treatment,  358 
use  of  metreurynter  in,  363 
Treatment     in     contractions    of    the 
pelvis,  386 
in  prolapse  of  cord,  374 
of  abortion,  419 
of  extrauterine  pregnancy,  439 
of  fractures,  168 

of  hematocele  in  extrauterine  preg- 
nancy, 441 
of  lacerations,  317,  321 
of  sepsis  following  abortion,  418 
of   the   unaffected   tube   in    extra- 
uterine pregnancy,  441 
of  the  transverse  position,  358 
postural,  in  correcting  faulty  atti- 
tudes of  the  fetus,  111 
in   favoring   spontaneous   evolu- 
tion in  cross-births,  358 
in  prolapse   of  cord,  371,  373 
to    favor    anterior    rotation    of 
head  in  occipito-posterior 
positions,  365 


INDEX 


465 


Trendelenburg  position,  28 

in  prolapse  of  the  cord,  371,  373 
Trephine,  211 
Trib'laded  cranioelast,  211 
Tubal   abortion,  435 

rupture  in  extrauterine  pregnancy, 
435 
Tuberculosis,  64 
of  the  larynx,  64 
of  the  lungs,  38 
Tucker-McLane  forceps,  196 
Tumors  complicating  pregnancy  and 
birth,  402 
of  the  ovaries,  402 
of  the  uterus,  404,  407 
of  the  vulva  and  vagina,  408 
Twilight  sleep,  35 
Twins,  247,  353 

birth  of  first  twin,  353 
birth  of  second  twin,  354 

danger  of  too  rapid  delivery  of, 
355 
interval,  354 

increased  danger  of  asphyxia  in, 

354 
possibility   of  fetal   death  from 
loss  of  blood  in,  354 
mortality  in  twin  births,  357 
unioval  twins,  354 
Tympanites  of  the  abdomen,  268 
of  the  uterus,  39 

U 

Ulna,  fractures  of,  167 
Umbilical    cord,     prolapse     of,     240, 
364,  366,  368,  392 
cesarean  section  in,  374 
colpeurynter  and  tampon,  use 

of,  in,  369 
danger  of,  368 
etiology  of,  368 
in  breech  presentation,  370 
in  foot  presentation,  371 
in  head  presentation,  372 
in  transverse  positions,  368 
pressure  on,  from  forceps,  204 
reposition  of,  373 
statistics,  373 
treatment,  371,  373 
Undeveloped  and  macerated  fetuses, 

114 
Unioval  twins,  354 
Ureter,  fistulse  of,  316 
Urethra,  contiscuous  structures  of,  94 
fistula  of,  105 
laceration  of,  105 


Urinary  bladder,  gangrene  of,  55 

lacerations       of,       accompanying 
pubiotomy  and  symphysi- 
otomy, 105 
prolapse  of,  323 

from     extension     of     vaginal 

tears,  320 
in  rupture  of  the  uterus,  312 
Urinary  fistulse,  105 
Urine   appearing   in   the   vagina,   sig- 
nificance  of,  323 
secretion  of,  in  eclampsia,  401 
Uterine  artery,  ligation  of,  314 
atony  following  birth  of  twins,  355 
myomata     {see     Uterus,     myomata 

of) 
wall,   penetration   of,   in   abortion, 
422 
Uteroabdominal  fistula,  268 
Uterus,  carcinoma  of,  407 
inoperable  cases,  407 
laparotomy,  407 
operable    cases,   407 
palliative  treatment,  407 
vaginal  operation,  407 
irritation  of,  in  atony,  284 

in    manual    detachment    of    the 
placenta,  296 
musculature  of,  228 
myomata  of,  404 

as  an  obstacle  to  birth,  404 
laparotomy   in,   405 
in  pregnancy,  405 
of  the  endometrium,  405 
in  the  placental  period,  404 
rupture   of,  308 

after   cesarean   section,  276 
complete,  312 
delivery   afterward,   313 
diagnosis,  312 
during  pregnancy,  276 
etiology,  138,  308 
hemorrhage,   314 
hemostasis,   314 
incomplete,   312 
prognosis,  312,  315 
prophylaxis,  313 
spontaneous,  315 
symptoms,  310 
threatening,   229 
treatment,  313 
tamponade  of,  in  atony,  292 
in   cesarean   section,  274 
in   cervical  tears,  317 
in  rupture  of,  314 


466 


INDEX 


V 

Vagina,  atresia  of,  244- 
bacteria  of,  21 
carcinoma  of,  408 
cysts  of,  408 
edema  of,  408 
tibroma  of,  408 
hematoma   of,   320 
lacerations  of,  319 
diagnosis,  321 
etiology,  319 
prognosis,  322 
symptoms,  320 
treatment,  321 
septum  in,  410 
stenosis  of,  410 
Vaginal   cesarean    section    (see   Cesa- 
rean section,  vaginal) 
douclie    in    inoperable    carcinoma, 

407 
operations  for  carcinoma  of  uterus 
for  cysts  of  the  vagina,  408 
for  myoma  of  uterus,  406 
for  ovarian  tumors,  402 
hysterectomy  in  abortion,  418 
in   carcinoma,  407 
in  infection,  271,  274 
in  rupture  of  uterus,  315 
hysterotomy,  175,  278 
tears,  diagnosis,  321 
etiology,  319 
symptoms,    320 
treatment,  321 
tumors,  408 
Vaginoperineal    incisions    (see    Episi- 

otomy) 
Vagus  nerve,  irritation  of,  49 
Varicosities  of  vulva,  409 
Veit-Smellie    method    of    delivering 
the      after-coming     head, 
150,    164,    165,    166,    169, 
224,  345 
Venesection  in  eclampsia,  400 
Veratrum  viride  in  eclampsia,  400 
Version   after  Braxton-Hicks,   130 
an  analysis  of  500  eases,  139 
and  extraction  in  birth  of  twins,  357 
in    contractions    of    the    pelvis, 

394,  395 
in  cross-births,  359 
in  placenta  previa,  345 
in  premature   separation   of  the 

placenta,  350 
in  prolapse  of  the  cord,  371,  374 
in  vaginal  cesarean  section,  283 
and  forceps  compared,  357,  394 
by  both  feet,  359 
by  the  head,  117 


Version  and  extraction — Cont  'd 
combined,  130 

compared  with  forceps,  394 
competing  operations,  95 
dangers  of,  to  child,  138 

to  mother,  137,  313 
difficulties  of,  134 
external,  117,  358  -  r     - 

indications  for,  117 
injuries  from,  138 
internal,  120 

preliminary   conditions,   120 
prognosis  in,  137 
sling,  use  of,  135 
statistics,  139 
technic  of,  117 
Vesicouterine  fold  of  peritoneum,  263 
Viability  of  the  child  as  an  index  to 
induction  of  labor,  59 
importance   of,   in  cesarean   sec- 
tion, 246 
Viburnum  j)runifolium  in  threatened 

abortion,  417 
Violence    as    a    cause    of    premature 
separation     of     the     pla- 
centa, 348 
Voorhees '  hydrostatic  bags,  78 
Vulval  injuries,  325 
tumors,  408 

bartholinitis,  409 
condylomata,  409 
edema,  408 
varicosities,  409 
Vulvovaginal  abscess,  409 

W 

Walcher  position,  30 

in  contracted  pelves,  393 

in    delivering    the    after-coming 

head,  164 
in  high  forceps  delivery,  196 

Washing  out  the  brain  substance  in 
perforation  and  cranioc- 
lasis,   217 

Water-head  (see  Hydrocephalus) 

Weak  labor  pains,  effect  of,  in  pla- 
centa previa,   343 

Weighted    traction    applied    to    the 
child's  body,  77,  239 
applied  to  the  metreurynter,  81 

Wertheim  's  angular  forceps,  272 

Wigand-Martin-Winckel  manipula- 
tion, 164,  165 

Wilson,  438 

Winter's  abortion  forceps,  434 

Wounds  about  the  clitoris,  338 


X 


X-ray,  167 


KG727 

Leavitt 

Operations  of  obstetrics. 


L48 


^^B  6  t^m 


